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Priapism in a child with chronic granulocytic leukemia
788
Brief clinical and laboratory observations
in cerebrospinal fluid is a n d salivary gland secretions. 14 This study shows t h a t electroimmunodiffusion is a p r a c t i c a l i m m u n o chemical technique for the m e a s u r e m e n t of I g A a n d I g M in umbilical cord serum.
SUMMARY Electroimmunodiffusion has been used to measure i m m u n o p r o t e i n s in various biologic fluids. D u r i n g a p e r i o d of 4 months, electroimmunodiffusion was used to q u a n t i t a t e concentrations of I g A a n d I g M in serum collected f r o m the umbilical cords of 97 unselected n e w b o r n infants. All samples cont a i n e d I g M , ranging f r o m 1.7 to 18.6 rag. p e r 100 ml. with a m e a n of 9.8 + 4.5 mg. p e r 100 ml. D e t e c t a b l e I g A , ranging from 0.5 to 5.8 mg. p e r 100 ml. with a m e a n of 2.6 + 1.7 mg. per 100 ml., was f o u n d in 29.9 p e r cent of the specimens. These d a t a suggest t h a t the fetus is c a p a b l e of synthesizing I g A a n d I g M , a n d t h a t they are present in concentrations w h i c h c a n be m e a s u r e d by sensitive i m m u n o c h e m i c a l techniques.
REFERENCES 1. Editorial: Immunoglobulin synthesis by the human fetus, New England J. Med. 277: 485, 1967. 2. Smith, R. T., and Eitzman, D. V.: Development of the immune response. Characterization of the response of the human infant and adult to immunization with Salmonella vaccines, Pediatrics 33: 163, 1964. 3. Silverstein, A. M.: Congenital syphilis and the timing of immunogenesis in the human fetus, Nature 194: 196, 1962.
Priapism in a child with chronic granulocytic leukemia R o b e r t G. G r a w , Jr., M . D . , R o l a n d T. Skeel, M . D . , and
Paul P. Carbone, M.D. BETHESDA,
MD.
The Journal of Pediatrics May 1969
4. van Furth, R., Schuit, H. R. E., and Hijmans, W.: Immunological development of the human fetus, J. Exper. Med. 122: 1173, 1965. 5. Stiehm, E. R., Ammann, A. J., and Cherry, J. D.: Elevated cord macroglobulins in the diagnosis of intrauterine infections, New England J. Med. 275: 971, 1966. 6. Alford, C. A., Schaefer, J., Blankenship, W. J., Straumfjord, J. V., and Cassady, G.: A cor#elative immunologic, microbiologic and clinical approach to the diagnosis of acute and chronic infections in newborn infants, New England J. Med. 277: 437, 1967. 7. Mancini, G., Carbonara, A. O., and Heremans, J. F.: Immunochemical quantitation of antigens by single radial immunodiffusion, Internat. J. Immunochem. 2: 235, 1965. 8. Fulginiti, V. A., Sieb.er, O. F., Jr., Claman, H. N., and Merrill, D.: Serum immunoglobulin measurements during the first year of life and in immunoglobulin deficiency states, J. PEDIAT. 68: 723, 1966. 9. Stiehm, E. R., and Fudenberg, H. H.: Serum levels of immune globulins in health and disease: A survey, Pediatrics 37: 715, 1966. 10. Thorn, H., McKay, E., and Gray, D.: Immunoglobulins in umbilical cord plasma. I. Healthy infants, Arch. Dis. Childhood 42: 259, 1967. 11. Merrill, D., Hartley, T. F., and Claman, H,. N.: Electroimmunodiffusion (EID): A simple, rapid method for quantitation of immunoglobulins in dilute biological fluids, J. Lab. & Clin. Med. 69: 151, 1967. 12. Smith, R. T.: In Smith, R., Miescher, P. A., and Good, R. A., editors: Ontogeny of immunity, Gainesville, 1967, University of Florida Press. 13. Hartley, T. F., Merrill, D. A., and Claman, H. N.: Quantitation of immunoglobulins in cerebrospinal fluid, Arch. Neurol. 15: 472, 1966. 14. Clasnan, H. N., Merrill, D. A., and Hartley, T. F.: Salivary immunoglobulins: Normal adult values and dissociation between serum and salivary levels, J. Allergy 40: 151, 1967.
PRIAPISM has long been discussed in textbooks of m e d i c i n e a n d early hematologic writings as a frequent complication of leukemia. 1, ~ T h e sparsity of cases r e p o r t e d in the recent l i t e r a t u r e indicates, however, that the occurrence of this entity m a y h a v e been overemphasized. 3-~ O n l y one previous case of c h i l d h o o d leukemia c o m p l i c a t e d by priapism has been reportedfi Because of the infrequency of the simultaneous occurrence of
From the Leukemia Service, Medicine Branch, National Cancer Institute, National Institute of Health.
Volume 74 Number 5
p r i a p i s m a n d childhood leukemia, this additional case is presented to p r o v i d e a basis for specific therapy. CASE REPORT
R. D. was a 7 89 Caucasian boy referred to the National Cancer Institute on April 10, 1962, for evaluation and treatment of chronic granulocytic leukemia. On February 24, 1962, the patient had developed an acute episode of priapism lasting only a few hours. During the night of February 27, the patient experienced a recurrence of the priapism. When it did not recede by the following morning he was seen by his private physician, who noted that the child also was pale and had splenomegaly. A hemoglobin and white blood cell count were performed and found to be 7 Gm. per 100 ml. and 337,000 per cubic milliliter, respectively. A platelet count was not performed. The peripheral blood smear was consistent with the clinical diagnosis of chronic granulocytic leukemia, and the child was admitted to the Lancaster, Pennsylvania, General Hospital. Over the next 4 days he received radiotherapy totaling 400 rads to the penis and surrounding tissue through a 6 • 8 cm. port and was started on oral busulfan, 6 rag. per day. Three days following the irradiation, the child developed urethral hemorrhage which continued for 2 weeks. During this 2 week period, the patient's penis returned to normal size. However, there was no change in his splenomegaly or peripheral blood count; after one week, the busulfan was discontinued and he was begun on oral 6-mercaptopurine, 2.5 mg. per kilogram per day. One month later the patient had not improved and was referred to the National Cancer Institute where the diagnosis of chronic granulocytic leukemia was confirmed by physical examination, peripheral blood counts, routine bone marrow examination, and leukocyte alkaline phosphatase. Hematologic examination revealed the following: hemoglobin, 9.0 Gm. per 100 ml.; platelet count, 2,860,000 per cubic millimeter; white blood cell count 259,000 per cubic millimeter with 30 per cent neutrophils, 26 per cent stab forms, 14 per cent metamyelocytes, 14 per cent myelocytes, 1 per cent promyelocytes, 8 per cent myeloblasts, 4 per cent eosinophils, 2 per cent lymphocytes, 1 per cent monocytes, and 2 nucleated RBC per 100 WBC. One hundred per cent of the analyzable metaphases in the cytogenetic preparation from bone marrow aspirate contained the Philadelphia chromosome (Ph:).
Brie[ clinical and laboratory observations
78 9
The chemotherapy was changed back to oral busulfan, 3 mg. per day since the patient had not improved while receiving 6-mercaptopurine. Six months later the spleen was no longer palpable, the WBC had dropped to 8,500 per cubic millimeter, and there had been no recurrence of the priapism. The patient's subsequent course was complicated by leukopenia and marked thrombocytopenia, and on May 23, 1963, a splenectomy was performed. Following the splenectomy, the peripheral platelet count rose to greater than 100,000 per cubic millimeter, and the patient was discharged on no therapy in June, 1963. Suddenly on November 27, 1963, he developed a cough and fever to 103 ~ F. and was found to have bronchopneumonia. A bone marrow examination revealed total replacement by immature granulocytic precursors. The infection was unresponsive to intravenous methicillin and leukocyte transfusions and the patient died 12/6/63, with rampant interstitial pneumonitis. DISCUSSION Priapism, or "persistent a b n o r m a l erection of the penis, usually w i t h o u t sexual desire, ''7 m a y ' o f t e n be painful. Its association with local irradiation, urethritis, urethral or b l a d d e r calculi, spinal cord disease, sickle cell anemia, thrombosis of the corpora cavernosa, and a d u l t myelogenous l e u k e m i a . is well knownS; however, the association with c h i l d h o o d leukemia is not. T h e mechanisms p r o p o s e d for priapism in adults with l e u k e m i a are (a) sludging and m e c h a n i c a l obstruction of the corpora cavernosa a n d dorsal veins of the penis by leukemic thrombosis, or (b) m e c h a n i c a l imp i n g e m e n t on a b d o m i n a l veins a n d nerves from an enlarged s p l e e n ? T h e first of these theories p r o b a b l y better explains the etiology of p r i a p i s m in o u r patient, since the spleen r e m a i n e d enlarged while the penis returned to n o r m a l size. Ritz a n d P u r f a r G r e p o r t e d an 8-year-old boy with chronic granulocytic leukemia who d e v e l o p e d priapism as an initial symptom. W h e n first seen, he h a d a leukocyte count of 430,000 p e r cubic millimeter. T h e p r i a p i s m persisted for 3 days despite conservative t h e r a p y with cold compresses, sublingual proteolytic enzymes, diethylstilbestrol, a n d vasodilatation with tolazoline hydrochloride. R a d i o t h e r a p y to the spleen (25 rads p e r day) was then initiated,
7 90
Brief clinical and laboratory observations
resulting in a decrease in the size of the penis to normal in 3 weeks. T h e occurrence of this entity with acute lymphocytic leukemia of childhood has never been reported and likewise has never been seen in 225 male children with acute lymphocytic leukemia treated at the National Cancer Institute since 1954. During this same interval 3 male children with chronic granulocytic leukemia have been treated, one of w h o m is the propositus. T h e association of priapism with chronic granulocytic leukemia rather than acute lymphocytic leukemia in children m a y be related to the more frequent concurrence of a normal to elevated platelet count and leukocytosis in patients with chronic granulocytic leukemia. Roentgen therapy has been used in the management of local leukemic infiltration 9 and has been applied to the spleen for treatment of chronic granulocytic leukemia 6 in doses approximating that used in our patient. Nowhere could we find recorded a report of urethral hemorrhagic discharge complicating the therapy of priapism as in our patient. Perhaps this resulted from a spontaneous or coincidental rupture of the corpora cavernosa into the urethra. In m a n y cases of adult leukemia and priapism, no specific therapy has been given for the priapism, or attempts at therapy of the priapism had been unsuccessful until specific antileukemic therapy had been instituted and a hematologic response had been seenY, 3 This evidence suggests that priapism is caused either by direct infiltration and sludging of the leukemic ceils or coagulation of the platelet-rich leukemic blood within the corpora cavernosa of the penis. Despite the infrequency of priapism, we believe that it is important for physicians to be aware of the possible benefit of radiotherapy to the penile area in priapism complicating leukemia, since the initial hematologic response m a y be long in coming and hence postpone the clearing of the penile vasculature. ADDENDUM
A report of priapism occurring in a 10-yearold boy with probable chronic granulocytic leu-
The Journal of Pediatrics May 1969
kemia has recently come to our attention. 1~ The priapism, of 2 weeks' duration, regressed completely, apparently in response to hot compresses applied for 3 weeks, despite a white blood cell count greater than 400,000 per cubic milliliter and a normal number of platelets. SUMMARY
A child with chronic granulocytic leukemia and priapism is presented to emphasize the rarity of this associated symptom-disease complex. Radiation therapy to the penile area resulted in a p r o m p t abatement of this complication before hematologic control of the underlying disease was achieved with busulfan. There was no recurrence of priapism even at the time of relapse and during" the accelerated terminal phase of the illness. T h e possible etiology of this rare condition is discussed. The authors wish to thank Dr. John M. Carper for referring the patient for care at the National Cancer Institute, and Dr. Edward S. Henderson for reviewing the manuscript. REFERENCES
1. Warthin, A. S.: Death due to leukemic infiltration of the larynx: Priapism persistent post mortem, myelold thromboses in the corpora cavernosa: Fatal hemorrhages from spleen after prolonged radiotherapy, Internat. Clin. 4: 280, 1909. 2. Wintrobe, M. M.: Clinical hematology, ed 6, Philadelphia, 1967, Lea & Febiger, Publishers, p. 1012. 3. Craver, L. F.: Priapism in leukemia, Surg. Clin. North America 13: 472, 1933. 4. Lowor, W., and Christoferson, L.: Priapism in leukemia, Cleveland Clin. Quart. 12" 133, 1945. 5. Haar, H., Shanbrom, E., and Miller, S.: The treatment of leukemic priapism with A-139, J. Urol. 83" 429, 1960. 6. Ritz, N. D., and Purfar, M.: Chronic myeloid leukemia with piapism in eight-year-old child, New York J. Med. 64" 553, 1964. 7. Dorland's Illustrated Medical Dictionary, ed. 24, PhiIadelphia, I965, W. B. Saunders Company, p. 1218. 8. Green, M., and Richmond, J. B.: Pediatri~ diagnosis, ed. 2, Philadelphia, 1962, W. B. Saunders Company, p. 124. 9. D'Angio, G. J., Evans, A. E., and Mitus, A.: Roentgen therapy of certain complications of acute leukemia in childhood, Am. J. Roentgenol. 82: 541, 1959. 10. Maciotta, G.: Priapism as a symptom of leukemic myelosis in a 10-year-old boy, Pediatria 42: 1093, 1934.
Brief clinical and laboratory observations
in cerebrospinal fluid is a n d salivary gland secretions. 14 This study shows t h a t electroimmunodiffusion is a p r a c t i c a l i m m u n o chemical technique for the m e a s u r e m e n t of I g A a n d I g M in umbilical cord serum.
SUMMARY Electroimmunodiffusion has been used to measure i m m u n o p r o t e i n s in various biologic fluids. D u r i n g a p e r i o d of 4 months, electroimmunodiffusion was used to q u a n t i t a t e concentrations of I g A a n d I g M in serum collected f r o m the umbilical cords of 97 unselected n e w b o r n infants. All samples cont a i n e d I g M , ranging f r o m 1.7 to 18.6 rag. p e r 100 ml. with a m e a n of 9.8 + 4.5 mg. p e r 100 ml. D e t e c t a b l e I g A , ranging from 0.5 to 5.8 mg. p e r 100 ml. with a m e a n of 2.6 + 1.7 mg. per 100 ml., was f o u n d in 29.9 p e r cent of the specimens. These d a t a suggest t h a t the fetus is c a p a b l e of synthesizing I g A a n d I g M , a n d t h a t they are present in concentrations w h i c h c a n be m e a s u r e d by sensitive i m m u n o c h e m i c a l techniques.
REFERENCES 1. Editorial: Immunoglobulin synthesis by the human fetus, New England J. Med. 277: 485, 1967. 2. Smith, R. T., and Eitzman, D. V.: Development of the immune response. Characterization of the response of the human infant and adult to immunization with Salmonella vaccines, Pediatrics 33: 163, 1964. 3. Silverstein, A. M.: Congenital syphilis and the timing of immunogenesis in the human fetus, Nature 194: 196, 1962.
Priapism in a child with chronic granulocytic leukemia R o b e r t G. G r a w , Jr., M . D . , R o l a n d T. Skeel, M . D . , and
Paul P. Carbone, M.D. BETHESDA,
MD.
The Journal of Pediatrics May 1969
4. van Furth, R., Schuit, H. R. E., and Hijmans, W.: Immunological development of the human fetus, J. Exper. Med. 122: 1173, 1965. 5. Stiehm, E. R., Ammann, A. J., and Cherry, J. D.: Elevated cord macroglobulins in the diagnosis of intrauterine infections, New England J. Med. 275: 971, 1966. 6. Alford, C. A., Schaefer, J., Blankenship, W. J., Straumfjord, J. V., and Cassady, G.: A cor#elative immunologic, microbiologic and clinical approach to the diagnosis of acute and chronic infections in newborn infants, New England J. Med. 277: 437, 1967. 7. Mancini, G., Carbonara, A. O., and Heremans, J. F.: Immunochemical quantitation of antigens by single radial immunodiffusion, Internat. J. Immunochem. 2: 235, 1965. 8. Fulginiti, V. A., Sieb.er, O. F., Jr., Claman, H. N., and Merrill, D.: Serum immunoglobulin measurements during the first year of life and in immunoglobulin deficiency states, J. PEDIAT. 68: 723, 1966. 9. Stiehm, E. R., and Fudenberg, H. H.: Serum levels of immune globulins in health and disease: A survey, Pediatrics 37: 715, 1966. 10. Thorn, H., McKay, E., and Gray, D.: Immunoglobulins in umbilical cord plasma. I. Healthy infants, Arch. Dis. Childhood 42: 259, 1967. 11. Merrill, D., Hartley, T. F., and Claman, H,. N.: Electroimmunodiffusion (EID): A simple, rapid method for quantitation of immunoglobulins in dilute biological fluids, J. Lab. & Clin. Med. 69: 151, 1967. 12. Smith, R. T.: In Smith, R., Miescher, P. A., and Good, R. A., editors: Ontogeny of immunity, Gainesville, 1967, University of Florida Press. 13. Hartley, T. F., Merrill, D. A., and Claman, H. N.: Quantitation of immunoglobulins in cerebrospinal fluid, Arch. Neurol. 15: 472, 1966. 14. Clasnan, H. N., Merrill, D. A., and Hartley, T. F.: Salivary immunoglobulins: Normal adult values and dissociation between serum and salivary levels, J. Allergy 40: 151, 1967.
PRIAPISM has long been discussed in textbooks of m e d i c i n e a n d early hematologic writings as a frequent complication of leukemia. 1, ~ T h e sparsity of cases r e p o r t e d in the recent l i t e r a t u r e indicates, however, that the occurrence of this entity m a y h a v e been overemphasized. 3-~ O n l y one previous case of c h i l d h o o d leukemia c o m p l i c a t e d by priapism has been reportedfi Because of the infrequency of the simultaneous occurrence of
From the Leukemia Service, Medicine Branch, National Cancer Institute, National Institute of Health.
Volume 74 Number 5
p r i a p i s m a n d childhood leukemia, this additional case is presented to p r o v i d e a basis for specific therapy. CASE REPORT
R. D. was a 7 89 Caucasian boy referred to the National Cancer Institute on April 10, 1962, for evaluation and treatment of chronic granulocytic leukemia. On February 24, 1962, the patient had developed an acute episode of priapism lasting only a few hours. During the night of February 27, the patient experienced a recurrence of the priapism. When it did not recede by the following morning he was seen by his private physician, who noted that the child also was pale and had splenomegaly. A hemoglobin and white blood cell count were performed and found to be 7 Gm. per 100 ml. and 337,000 per cubic milliliter, respectively. A platelet count was not performed. The peripheral blood smear was consistent with the clinical diagnosis of chronic granulocytic leukemia, and the child was admitted to the Lancaster, Pennsylvania, General Hospital. Over the next 4 days he received radiotherapy totaling 400 rads to the penis and surrounding tissue through a 6 • 8 cm. port and was started on oral busulfan, 6 rag. per day. Three days following the irradiation, the child developed urethral hemorrhage which continued for 2 weeks. During this 2 week period, the patient's penis returned to normal size. However, there was no change in his splenomegaly or peripheral blood count; after one week, the busulfan was discontinued and he was begun on oral 6-mercaptopurine, 2.5 mg. per kilogram per day. One month later the patient had not improved and was referred to the National Cancer Institute where the diagnosis of chronic granulocytic leukemia was confirmed by physical examination, peripheral blood counts, routine bone marrow examination, and leukocyte alkaline phosphatase. Hematologic examination revealed the following: hemoglobin, 9.0 Gm. per 100 ml.; platelet count, 2,860,000 per cubic millimeter; white blood cell count 259,000 per cubic millimeter with 30 per cent neutrophils, 26 per cent stab forms, 14 per cent metamyelocytes, 14 per cent myelocytes, 1 per cent promyelocytes, 8 per cent myeloblasts, 4 per cent eosinophils, 2 per cent lymphocytes, 1 per cent monocytes, and 2 nucleated RBC per 100 WBC. One hundred per cent of the analyzable metaphases in the cytogenetic preparation from bone marrow aspirate contained the Philadelphia chromosome (Ph:).
Brie[ clinical and laboratory observations
78 9
The chemotherapy was changed back to oral busulfan, 3 mg. per day since the patient had not improved while receiving 6-mercaptopurine. Six months later the spleen was no longer palpable, the WBC had dropped to 8,500 per cubic millimeter, and there had been no recurrence of the priapism. The patient's subsequent course was complicated by leukopenia and marked thrombocytopenia, and on May 23, 1963, a splenectomy was performed. Following the splenectomy, the peripheral platelet count rose to greater than 100,000 per cubic millimeter, and the patient was discharged on no therapy in June, 1963. Suddenly on November 27, 1963, he developed a cough and fever to 103 ~ F. and was found to have bronchopneumonia. A bone marrow examination revealed total replacement by immature granulocytic precursors. The infection was unresponsive to intravenous methicillin and leukocyte transfusions and the patient died 12/6/63, with rampant interstitial pneumonitis. DISCUSSION Priapism, or "persistent a b n o r m a l erection of the penis, usually w i t h o u t sexual desire, ''7 m a y ' o f t e n be painful. Its association with local irradiation, urethritis, urethral or b l a d d e r calculi, spinal cord disease, sickle cell anemia, thrombosis of the corpora cavernosa, and a d u l t myelogenous l e u k e m i a . is well knownS; however, the association with c h i l d h o o d leukemia is not. T h e mechanisms p r o p o s e d for priapism in adults with l e u k e m i a are (a) sludging and m e c h a n i c a l obstruction of the corpora cavernosa a n d dorsal veins of the penis by leukemic thrombosis, or (b) m e c h a n i c a l imp i n g e m e n t on a b d o m i n a l veins a n d nerves from an enlarged s p l e e n ? T h e first of these theories p r o b a b l y better explains the etiology of p r i a p i s m in o u r patient, since the spleen r e m a i n e d enlarged while the penis returned to n o r m a l size. Ritz a n d P u r f a r G r e p o r t e d an 8-year-old boy with chronic granulocytic leukemia who d e v e l o p e d priapism as an initial symptom. W h e n first seen, he h a d a leukocyte count of 430,000 p e r cubic millimeter. T h e p r i a p i s m persisted for 3 days despite conservative t h e r a p y with cold compresses, sublingual proteolytic enzymes, diethylstilbestrol, a n d vasodilatation with tolazoline hydrochloride. R a d i o t h e r a p y to the spleen (25 rads p e r day) was then initiated,
7 90
Brief clinical and laboratory observations
resulting in a decrease in the size of the penis to normal in 3 weeks. T h e occurrence of this entity with acute lymphocytic leukemia of childhood has never been reported and likewise has never been seen in 225 male children with acute lymphocytic leukemia treated at the National Cancer Institute since 1954. During this same interval 3 male children with chronic granulocytic leukemia have been treated, one of w h o m is the propositus. T h e association of priapism with chronic granulocytic leukemia rather than acute lymphocytic leukemia in children m a y be related to the more frequent concurrence of a normal to elevated platelet count and leukocytosis in patients with chronic granulocytic leukemia. Roentgen therapy has been used in the management of local leukemic infiltration 9 and has been applied to the spleen for treatment of chronic granulocytic leukemia 6 in doses approximating that used in our patient. Nowhere could we find recorded a report of urethral hemorrhagic discharge complicating the therapy of priapism as in our patient. Perhaps this resulted from a spontaneous or coincidental rupture of the corpora cavernosa into the urethra. In m a n y cases of adult leukemia and priapism, no specific therapy has been given for the priapism, or attempts at therapy of the priapism had been unsuccessful until specific antileukemic therapy had been instituted and a hematologic response had been seenY, 3 This evidence suggests that priapism is caused either by direct infiltration and sludging of the leukemic ceils or coagulation of the platelet-rich leukemic blood within the corpora cavernosa of the penis. Despite the infrequency of priapism, we believe that it is important for physicians to be aware of the possible benefit of radiotherapy to the penile area in priapism complicating leukemia, since the initial hematologic response m a y be long in coming and hence postpone the clearing of the penile vasculature. ADDENDUM
A report of priapism occurring in a 10-yearold boy with probable chronic granulocytic leu-
The Journal of Pediatrics May 1969
kemia has recently come to our attention. 1~ The priapism, of 2 weeks' duration, regressed completely, apparently in response to hot compresses applied for 3 weeks, despite a white blood cell count greater than 400,000 per cubic milliliter and a normal number of platelets. SUMMARY
A child with chronic granulocytic leukemia and priapism is presented to emphasize the rarity of this associated symptom-disease complex. Radiation therapy to the penile area resulted in a p r o m p t abatement of this complication before hematologic control of the underlying disease was achieved with busulfan. There was no recurrence of priapism even at the time of relapse and during" the accelerated terminal phase of the illness. T h e possible etiology of this rare condition is discussed. The authors wish to thank Dr. John M. Carper for referring the patient for care at the National Cancer Institute, and Dr. Edward S. Henderson for reviewing the manuscript. REFERENCES
1. Warthin, A. S.: Death due to leukemic infiltration of the larynx: Priapism persistent post mortem, myelold thromboses in the corpora cavernosa: Fatal hemorrhages from spleen after prolonged radiotherapy, Internat. Clin. 4: 280, 1909. 2. Wintrobe, M. M.: Clinical hematology, ed 6, Philadelphia, 1967, Lea & Febiger, Publishers, p. 1012. 3. Craver, L. F.: Priapism in leukemia, Surg. Clin. North America 13: 472, 1933. 4. Lowor, W., and Christoferson, L.: Priapism in leukemia, Cleveland Clin. Quart. 12" 133, 1945. 5. Haar, H., Shanbrom, E., and Miller, S.: The treatment of leukemic priapism with A-139, J. Urol. 83" 429, 1960. 6. Ritz, N. D., and Purfar, M.: Chronic myeloid leukemia with piapism in eight-year-old child, New York J. Med. 64" 553, 1964. 7. Dorland's Illustrated Medical Dictionary, ed. 24, PhiIadelphia, I965, W. B. Saunders Company, p. 1218. 8. Green, M., and Richmond, J. B.: Pediatri~ diagnosis, ed. 2, Philadelphia, 1962, W. B. Saunders Company, p. 124. 9. D'Angio, G. J., Evans, A. E., and Mitus, A.: Roentgen therapy of certain complications of acute leukemia in childhood, Am. J. Roentgenol. 82: 541, 1959. 10. Maciotta, G.: Priapism as a symptom of leukemic myelosis in a 10-year-old boy, Pediatria 42: 1093, 1934.