Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review

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Here, we report an 18-year-old male presenting with a persistent erection of the penis for 20 days. We evaluated and compared the reported cases within 20 years discussing the management of priapism in CML. Cytoreductive therapy followed by leukapheresis, the administration of tyrosine kinase inhibitor, and intra-cavernosal blood aspiration may resolve the symptoms of priapism. Early intervention for cytoreduction and aspiration are the pivotal keys to successfully impeding the complications." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/10-571/v2", "name": "Case Report: Priapism as The Clinical Presenting Feature of Chronic..." } } ] } Home Browse Case Report: Priapism as The Clinical Presenting Feature of Chronic... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Bintoro SUY, Romadhon PZ, Suryantoro SD et al. Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.12688/f1000research.53365.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] Previously titled: 'Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-year Literature Review' Siprianus Ugroseno Yudho Bintoro https://orcid.org/0000-0003-1360-5298 1,2 , Pradana Zaky Romadhon https://orcid.org/0000-0001-9306-5425 1,2 , Satriyo Dwi Suryantoro https://orcid.org/0000-0002-0522-8659 1,3 , Rusdi Zakki Aminy https://orcid.org/0000-0002-6927-7206 1 , Choirina Windradi https://orcid.org/0000-0002-3394-1400 3 , Krisnina Nurul Widiyastuti 1 Siprianus Ugroseno Yudho Bintoro https://orcid.org/0000-0003-1360-5298 1,2 , Pradana Zaky Romadhon https://orcid.org/0000-0001-9306-5425 1,2 , [...] Satriyo Dwi Suryantoro https://orcid.org/0000-0002-0522-8659 1,3 , Rusdi Zakki Aminy https://orcid.org/0000-0002-6927-7206 1 , Choirina Windradi https://orcid.org/0000-0002-3394-1400 3 , Krisnina Nurul Widiyastuti 1 PUBLISHED 13 Jan 2022 Author details Author details 1 Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, East Java, 60131, Indonesia 2 General Teaching Hospital Dr. Soetomo, Surabaya, East Java, 60286, Indonesia 3 Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia Siprianus Ugroseno Yudho Bintoro Roles: Conceptualization, Formal Analysis, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Pradana Zaky Romadhon Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Satriyo Dwi Suryantoro Roles: Conceptualization, Formal Analysis, Methodology, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rusdi Zakki Aminy Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Choirina Windradi Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Krisnina Nurul Widiyastuti Roles: Conceptualization, Data Curation, Formal Analysis, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Priapism in chronic myeloid leukemia (CML) appears to be an infrequent manifestation as well as a crucial emergency. Here, we report an 18-year-old male presenting with a persistent erection of the penis for 20 days. We evaluated and compared the reported cases within 20 years discussing the management of priapism in CML. Cytoreductive therapy followed by leukapheresis, the administration of tyrosine kinase inhibitor, and intra-cavernosal blood aspiration may resolve the symptoms of priapism. Early intervention for cytoreduction and aspiration are the pivotal keys to successfully impeding the complications. READ ALL READ LESS Keywords priapism, chronic myeloid leukemia, cytoreduction, penile-aspiration, cancer Corresponding Author(s) Pradana Zaky Romadhon ( [email protected] ) Close Corresponding author: Pradana Zaky Romadhon Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2022 Bintoro SUY et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Bintoro SUY, Romadhon PZ, Suryantoro SD et al. Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.12688/f1000research.53365.2 ) First published: 15 Jul 2021, 10 :571 ( https://doi.org/10.12688/f1000research.53365.1 ) Latest published: 13 Jan 2022, 10 :571 ( https://doi.org/10.12688/f1000research.53365.2 ) Revised Amendments from Version 1 As advised by the reviewer, we have simplified the title, paid attention to unclear sentences, removed and revised them. We also have added one recommended reference to our discussion. As advised by the reviewer, we have simplified the title, paid attention to unclear sentences, removed and revised them. We also have added one recommended reference to our discussion. See the authors' detailed response to the review by Ritu Gupta READ REVIEWER RESPONSES Introduction Priapism is a urological emergency due to persistence of an erection lasting more than 4 hours, whether or not it is related to sexual influence. 1 Priapism is a rare condition with an incidence of 1–5 cases per 100,000 people per year. Penile erection in priapism is regularly painless. There are two types of priapism, which are low-flow priapism and high-flow priapism. Low-flow priapism is provoked by a pathological condition of low venous blood flow causing stasis in the penile vessels. This condition is an emergency condition that can result in cell damage and fibrosis, thus it often requires immediate therapy. Meanwhile, high-flow priapism is caused by increased blood flow to the sinusoid arteries without offsetting the flow to the veins. One of the causes of high-flow abnormalities is penile injury, while low-flow priapism is commonly caused by blood disorders such as sickle cell anemia and chronic myeloid leukemia (CML). 2 – 4 Priapism accounts for 20% of the hematological abnormalities while 1–5% of priapism are due to leukemia. The theory behind a priapism is the dysregulation of nitric oxide (NO) in penile vascularization. This occurs due to changes in NO synthase enzyme activity which decrease NO production by the corpora cavernosa. This ischemic condition induces platelet aggregation, thrombus, and tissue damage. Decreased NO interferes with smooth muscle tone and generates the priapism. Hyperviscosity conditions due to leukocytosis and adenosine-opiorphins abnormalities is also involved in this condition. 1 Currently, the approach to treat CML patients with priapism uses a combination of systemic therapy (chemotherapy with hydroxyurea or tyrosine kinase inhibitors and leukapheresis) and local intracavernosal therapy. Some cases with late manifestations cause erectile dysfunction, gangrene and penile abscess. 5 This case report and review aims to discuss the clinical characteristics and outcomes of CML patients who experience priapism. Case An 18-year-old unmarried male student, presented at the ER complaining of persistent erection of the penis. The patient complained of persistent erected penis for 20 days before admission. There was no phase without an erection in between. Previously, there was neither history of trauma to sexual stimulation, nor consumption of certain drugs. The patient also complained of mild genital pain along with the onset of erection. There were no complaints about discoloration of the penis; becoming reddish, bluish, or pale, also there was no numbness. The patient could urinate normally (see Figure 1 ). Figure 1. Penis at day 2, day 6 (after intracavernosal blood aspiration), and day 9. The patient complained of tinnitus in his right and left ears for 15 days accompanied by blurred vision. The patient also felt that his left side of stomach was slowly enlarging for 5 months. There was no bleeding and fever. Before coming to the ER, the patient was hospitalized at the regional hospital and received a blood transfusion and was diagnosed with a blood disorder. Physical examination revealed no anemia and icterus. The spleen was palpable showing Schuffner 4 and Hackett 3. There was no enlargement of the lymph nodes. His laboratory findings were hemoglobin 10.4 g/dL; leucocytes 421,000 cells/mm 3 ; platelets 407,000 cells/mm 3 ; white blood cells differential 4.3/6.8/81.3/4.9/2.7; blood urea nitrogen 9 mg/dL; serum potassium 0.5 mg/dL, uric acid 6.5 mg/dL. Peripheral blood smear showed normochromic anemia, normocytic anisopoikilocytosis, leukocytosis (3% myeloblasts, 6% promyelocytes, 4% myelocytes, 2% metamyelocytes, 5% stab neutrophils, 63% segment neutrophils, 4% eosinophils, 6% basophils, 5% lymphocytes, 2% monocytes, atypical lymphocytes (+)) concluded as CML. The patient received hydroxyurea 2000 mg once daily at night, paracetamol 500 mg TID, and an urgent leukapheresis. The patient underwent leukapheresis once per day (three times since initial admission) with gradual improvement. Unfortunately, on the fourth day of treatment the patient felt a penis erection again with pain on a scale of 0–5. Local examination of the genitalia showed a maximal erected penis, with no discoloration indicative of hyperemia, cyanosis, or pallor. Blood gas analysis showed pH 6.95, pCO 2 64 mmHg, HCO 3 14 mEQ/L, BE -18 unit. We concluded that the patient had ischemic priapism. Therefore, the patient underwent intracavernous aspiration producing 150 mL blood. Not long after that, the patient's penis returned to an erection with bleeding from the puncture wound. We then decided to give leukapheresis to the patient. On the eighth day of treatment, the erection improved with pain scale of 1. Quantitative BCR–ABL examination showed a positive result of 65%, thus the administration of hydroxyurea was stopped and replaced by imatinib 400 mg once daily at night. On the twelfth day of treatment, the erection completely resolved and the patient was successfully discharged from the hospital. Discussion This review presents data on patients who have priapism due to CML (see Table 1 ). Priapism occurred in the age ranging from 9–53. Patients usually had episodes of priapism for 18 h to 7 days. Not all patients with priapism showed a typical clinical examination of CML in the form of splenomegaly, but all of these patients had a hyperleukocytosis profile with a leukocyte count >200,000 cells/mm 3 . Some of them are equipped with data of peripheral blood smear with excessive blast and identification of BCR–ABL gene. A study by Minckler et al. was the only one reporting a resolved erection with a cold shower, whilst most other cases needed medical intervention. 6 Although the duration of symptoms varied, four cases reported complications following an episode of priapism. Patients with unfavorable outcomes once received hydroxyurea, imatinib but failed to undergo urological emergency therapy such as intra-cavernosa aspiration, surgical intervention, and embolization. Table 1. Case report review from last than twenty years. No Author Country Year Age Duration of priapism Diagnosis of CML Treatment of CML Treatment of priapism Outcome of the treatment 1 Gaye et al . 4 Senegal 2020 46 48 hours White Blood Cell: 526000/mm 3 , Platelets: 412000/mm 3 , Myelogram result: bone marrow hyperplasia. Karyotyping: Translocation between chromosomes 9 and 22 Imatinib (the dosage wasn’t mentioned) Aspiration of corpora cavernosa, injection of phenylephrine, hydrocycarbamide Success 2020 9 36 hours White Blood Cell: 82000/mm 3 , Platelets: 81000/mm 3 , BMA: acute myeloid leukemia Vincristine and Prednisolone penile skin refrigeration, rehydration, puncture of corpora cavernosa, injection of phenylephrine Success 2 Rajabto et al . 9 Indonesia 2020 44 4 days physical exam: pale skin, conjunctival pallor, leukemic retinopathy in both eyes. Schuffer 2. IV fluid, Allopurinol 300 mg, Sodium bicarbonate 500 mg 3 times daily, hydrocyurea 1 gram three, Imatinib 400 mg times a day aspiration of penile corpus, injection of epinephrine suffered ED Labs: anemia, hyperleukocytosis, microcytic hypochromic, anisopoikilocytosis, fragmentocytes, polychromic erythrocytes, a left shift, platelet count (355,000/μL), and hyperleukocytosis (399.560/μL). Positive BCR-ABL1 BMA: hypercellularity 3 Dhar et al . 11 India 2019 52 4 hours Physical examination: massive splenomegaly of 8 cm below the left costal margin along with hepatomegaly of 3 cm below right costal margin. Hydroxyurea 500 mg TDS, Imatinib OD, Allupurinol 300 mg OD, adequate hydration needle aspiration --> didn’t work, went for Winters procedure Success Blood count: left sided granulopoeis, total leucocyte count of 239×109/L and platelet count of 625×109/L. BMA: findings of CML positive translocation of BCR-ABL 4 Becerra et al . 12 Mexico 2018 52 6 day evolution WBC: 282.000, platelets: 368×10 3 /mm 3 dastinib 100 mg/day+G15 corpora cavernosa irrigation and surgery penis shunts Success BMA: acute phased CML translocation t (9:22)(q34;q11.2) with P210 BCR-ABL1 fusion transcriber 5 Khan et al . 13 Pakistan 2018 16 264 hours Leukocyte count: 614.8×10 9 , platelets 709×10 12 /L, peripheral smear: myeloid hyperplasia, neutrophilia. BMA: myeloid hyperplasia. Detection of BCR-ABL Hydroxyurea, allopurinol Glans-cavernosal shunt Achieved detumescence, No info on ED 6 Qu et al . 14 China 2018 18 72 hours Hepatosplenomegaly 2-3 cm under arcus costae, blood count: white blood cell (WBC) 257×10 9 /L and platelets (PLT) 5450×10 9 /L Imatinib Caverosa-corpus spongiosum shunt No ED at 3 months follow up 7 Clark et al . 15 USA 2018 13 3 days Blood count: WBC count of 350,000/mL (350×10 9 /L) and platelet count of 450×10 3 /mL (450×10 9 /L). Flow cytometry of blood: granulocytosis with no increase in blasts leukapharesis, IV fluids, hydroxyurea, allupurinol, Imatinib phenylephrine injection, three times corporeal irrigation improved with phallus rigidity and tenderness BMA: Philadephia chromosome 8 Kumar et al . 16 India 2018 47 5 days Hepatosplenomegaly, WBC: 279×109, 91.2%BCR Hydroxyurea, Imatinib Aspiration and irrigation with phenlyephrine, Winter's T Shunt Successful treatment 42 7 days Splenomegaly 6 cm below costal margin, WBC: 390×109/L, 70,7% BCR-ABL ratio Hydroxyurea, Imatinib Aspiration and irrigation Successful treatment 28 6 days No hepatosplenomegaly, WBC: 206×109/L, 75.3% BCR-ABL ratio Hydroxyurea, Imatinib Aspiration and irrigation with phenlyephrine, Winter's T Shunt Successful treatment 9 Sun et al . 5 USA 2018 27 8 years, persistent erection 9 hours Labs: anemia, WBC 450,010, Platelets 509,000/mm 3 BMA: 2% blasts, hypercellular bone marrow, granulocytic hyperplasia, small megakaryocytes. BCR-ABL did not reveal clonal evolution. Leukapheresis, hydoxyurea 500 mg daily, allopurinol 300 mg daily, Imatinib 400 mg daily, Corporal bpody aspiration, 1 dose of phenylephrine injection Successful treatment 10 Huei et al . 17 Malaysia 2018 28 48 hours hepatomegaly 2cm below right costal margin, splenomegaly, anemia, WBC 294×10 9 , platelets: 94×10 9 /L Peripheral blooad smear: hyperleucocytosis, blast cells Hydroxyurea, allupurinol, intravenous Cytarabine Intracavernosal aspiration, phenylephrine irrigation--> detumescent --> reccurent erection --> corpoglandular shunt Successful treatment 11 Minckler et al . 6 USA 2017 18 3 month intermittent WBC: 588×10 3 /uL, platelets: 109×10 3 /uL Hydroxyurea transtition to imatinib 400 mg daily Penile irigation and aspiration Success peripheral blood: hyperleukocytosis with absolute neutrophilia and a peripheral blast count of 2%. bone marrow aspirate and biopsy: hypercellular marrow with 4% blasts FISH analysis: translocation t(9:22) 12 Nerli RB et al . 7 India 2016 19 duration: 24 hours WBC 296800, platelet 936,000/mm 3 , BMA: hypercellular, increased megakaryocytes Hydroxyurea 1.5 gram daily, Imatinib 40 mg daily Allupurinol 300mg daily per oral Irrigation, decompression Successful 13 Ergenc H et al . 18 Turkey 2015 18 duration: 72 hours Hepatosplenomegaly 2-3 cm under arcus costae, anemia, WBC 100.000, platelets 1,002,000/mm, peripheral blood smear: immature leukocytes. BMA: hypercellularity with myeloid hyperplasia, positive BCR-ABL translocation Imanitib 400 mg once daily, allopurinol 300 mg once daily, leukapharesis not mentioned Success 14 Shaeer et al . 2 Egypt 2015 21 6 days palpable splenomegaly, WBC 410000, Philadelphia chromosome translocation Leukapharesis, Imatinib 400 mg daily failed several cavernosal aspiration and injection of epinephrine --> penile prosthesis No complication throughout 6 months-follow up 15 Osorio et al . 19 Spain 2014 24 14 hours, the second episode. The first episode was 4 months ago WBC: 177.15×109, platelet was not mentioned, cytogenic diagnosis: showing CML Imatinib Corpora cavernosa aspiration, intracavernosa fenilefrin injection not mentioned 29 6 hours, the second episode. The first episode was less than a month ago WBC: 402.24×109, platelet was not mentioned positive BCR-ABL hyrdoxyurea Corpora cavernosa aspiration, intracavernosa fenilefrin injection not mentioned 16 Hazra et al . 20 India 2013 14 24 hours Splenomegaly 6 cm below the left costal margin, anemia, WBC 226900, platelets 310,000/uL, Peripheral blood smear: immature leukocytes in various stages. BMA: CML. Hydroxyurea 50 mg/kgBB/day, Allupurinol 300 mg/day Cavernosal aspiration and phenylephrine irrigation No recurrence at 2-months-follow-up 17 Veljkovic et al . 21 Serbia 2012 16 24 hours Splenomegaly 4 cm below costal margin, WBC 320×109/L, Platelet (Plt) 417×10 9 /L BMA: extreme hypercellularity, BCR/ABL positive leukapharesis, cytoreductive chemotherapy leukapharesis no follow up 18 Paladino et al . 3 Spain 2011 16 48 hours Splenomegaly, WBC 312.000, PLT: 60.000/mm 3 BMA: showing CML no mention Corpora cavernosa drainage Erectile dysfunction 19 Gupta et al . 22 India 2009 12 48 hours Hepatosplenomegaly below the costal margins, anemia, WBC: 346×109/L, platelet count of 40,000/mm 3 , peripheral blood smear: immature myeloid leukocytosis. Cytogenesis: philadelphia chromosome. BCR-ABL transcript was positive hydroxyurea 4g/day IV fluid 3L/day, allopurinol, Imatinib 400mg/day, leukapharesis Terbutaline 0.125 mg subcutaneously Resolved by 24 h 20 Ilais Tazi 23 Morocco 2009 33 duration: 22 hours Palpable splenomegaly 4 cm below left costal margin, WBC: 400000/mm 3 , platelets 1200000/mm 3 . Peripheral blood smear: immature leukocytes. Karyotyple analysis: Ph1 chromosome, myeloid hyperplasian in the bone marrow. Imatinib Aspiration Success 21 Castagnetti et al . 24 Netherland 2008 9 several days splenomegaly, anemia, WBC: 509×109/L, philadelphia chromosome, BCR-ABL + Hydroxyurea 1.5mg/m 2 /day, Cyclophosphamide 250 mg/m 2 /day for 2 days, leukopharesis cytoreduction, antibiotics, anticoagulants Fully resolved after 1 month 9 96 hours mild splenomegaly Hydroxyurea 1g/m 2 /day LMWH 90 units/kg SQ BID for 1 month, metamizole fully resolved after 3 months 9 9 hours hepatosplenomegaly Cyclophosphamide 250 mg/m 2 /day for 2 days, leukapharesis LMWH 90 units/kgBB SQ BID for 9 days, metamizole, morphine fully resolved after 20 days 22 Yoshida et al . 25 Japan 2007 29 48 hours WBC 263000 Imatinib mesylate Winter procedure no evidence of recurrent 23 Lopez et al . 26 Spain 2004 29 10 hours WBC 414×10 9 /L, BMA: hypercellularity, PLT: 1100 × 10 9 /L corpora cavernosa aspiration, phenylephrine injection corpus cavernosum aspiration, fenilefrin injection Successful treatment 24 Ponniah et al . 27 United Kingdom 2004 19 18 hours WBC 513×109/L Leukapharesis failed cavernosal aspiration + leukapharesis No ED on follow up 25 Dogra et al . 28 India 2003 18 10 days hepatosplenomegaly, anaemic, WBC 320000, PLT was not mentioned Intravenous hydration, furosemide, sodium bicarbonate, hydroxyurea, allopurinol, leukapharesis Winters Procedure impotent and enlarged penis at 3-months follow up 26 Meng-Wei Chang et al . 8 Taipei 2003 21 19 hours Hepatomegaly 6 cm below right arcus costae, Splenomegaly 7 cm below left arcus costae, anemia, WBC 216800, Platelet 1746,000/mm 3 Interferon alfa-2a (6MIU/vial), allopurinol 300 mg daily Aspiration, epinephrine irigation Success 27 Guerra et al . 29 Spain 2002 53 12 hours WbC 968×109/L Hydroxyurea Corpora cavernosa aspiration Successful treatment 28 Murayama et al . 30 Japan 2001 14 4 days WBC 510000, BMA: myeloid hyperplasia, karyotype analysis: chromosome Ph1 urokinase, hydroxyurea embolization of bilateral pudendal artery Reduced sexual potency 29 Rojas et al . 31 Chilli 1998 22 duration: 36 hours none Leukapharesis Surgical intervention Unsuccessful (post treatment sexual dysfunction) The patient in our study was 18 years old. However, based on the literature, patients in every age group are at risk of developing priapism. There are two peaks in the age distribution that tend to experience this condition. The peak in earlier age is between 5 and 10 years, especially in patients with sickle cell disease. Meanwhile, the second peak is at sexually active phase between 20 and 50 years. Apart from hypercoagulability, this condition may also be related to the abuse of erectile drugs. 7 History and physical examination are important when encountering cases of priapism. Laboratory tests are required to check for impaired coagulation and serum electrolytes. Some patients who are at high risk for priapism include users of intracorporal injection therapy for erectile dysfunction, coagulation disorders such as sickle cell disease and CML. 2 , 4 In CML, hyperleukocytosis is thought to be the prime cause of priapism. The main mechanism is the aggregation of leukemic cells in the corpora cavernosa and dorsal veins of the penis. Other than that, mechanical pressure in the abdominal veins due to the enlargement of the spleen might also increase the risk. 1 The data needed in the management of patients with this case are erection duration, pain scale, trauma, complete blood count, peripheral blood smear, penile blood gas analysis, bone marrow and polymerase chain reaction for BCR–ABL1 if necessary. 1 , 2 , 4 In CML, the most common type of priapism is the ischemic one (veno-occlusive). Patients usually complain of painful, rigid erection, with reduced to no cavernous blood flow at all. Priapism that lasts for more than 4 hours indicates a compartment syndrome and may require emergent medical intervention. 8 The American Urological Association recommends that systemic treatment of an underlying disorder should not be the only one therapy for ischemic priapism. In this case, the patient had an erectile episode since 20 days before the admission. This phenomenon was likely due to the compartment syndrome, hence the intra-cavernous aspiration was required. 1 The intra-cavernous aspiration procedure can be accomplished by giving the anesthetic injection first under the symphysis pubis. The penis is tied with a tourniquet followed by insertion of a 16–18-Gauge bivalve intravenous catheter into the corpus cavernosum. When the two corpora are fused, aspiration of 20–30 mL of blood can be undertaken. This procedure has 30% chances of success. 8 , 9 Systemic therapy is often used to reduce hyperviscosity is cytoreductive therapy such as high-dose hydroxycarbamide and tyrosine kinase inhibitors (TKI) with or without apheresis procedures. Hydroxycarbamide can be given 2–6 grams divided into four doses per day. This can reduce leukocytes by almost 60% in 24–48 h. In addition, TKI, such as imatinib, can be administered as soon as the diagnosis is confirmed. The recommended dose of imatinib is 400 mg once daily in the chronic phase, 600–800 mg once daily in the accelerated phase, and 800 mg once daily in a blast crisis. 9 Generally, IRIS study describes the effectiveness of imatinib therapy for complete hematological response (CHR), major cytogenetic response (McyR) and complete cytogenetic response (CcyR). 4 Leukapheresis can promote a rapid decrease in intravascular leukemic cells, improve tissue perfusion and prevent leukostasis (generally show pulmonary and central nervous system manifestations). Once leukapheresis is given, it possibly can reduce the leukocyte count by 30–60%. However, compared to the chemotherapy, several previous studies have shown that this procedure had high all-cause mortality. According to 2016 apheresis guidelines, category 2 (second-line therapy) is recommended for grade 1B of acute myeloid leukemia (strong recommendation, moderate quality evidence), while category 3 (unclear role of apahresis) is recommended for acute lymphoblastic leukemia cases grade 2C (weak recommendation, low quality evidence). In this guideline, leukapheresis is not recommended for chronic myeloid leukemia. 10 Several cases of priapism in this case review reported a successful combination of leukapheresis with systemic oral CML therapy. A study by Rojas et al. was the only one reporting a failed leukapheresis. This case report and review presents a comparative presentation of patient characteristics, clinical characteristics of CML, laboratory profile, and therapeutic intervention for CML with priapism. Clinical presentation and early intervention are pivotal keys to achieve favorable outcome and prevent complications. Systemic intervention combined with intraurethral therapy may add the success rate (see Figure 2 ). Figure 2. Treatment and outcome from priapism and CML. Eventually, further discussion and study on other causes of priapism is essential as a meta-analysis stated that priapism might also be related to lymphoproliferative disorders. 32 Consent Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient. Data availability All data underlying the results are available as part of the article and no additional source data are required. References 1. Rodgers R, Latif Z, Copland M: How I manage priapism in chronic myeloid leukaemia patients. Br J Haematol. 2012; 158 (2): 155–64. PubMed Abstract | Publisher Full Text 2. Shaeer OK, Shaeer KZ, AbdelRahman IF, et al. : Priapism as a result of chronic myeloid leukemia: case report, pathology, and review of the literature. J Sex Med. 2015; 12 (3): 827–34. 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Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 15 Jul 2021 ADD YOUR COMMENT Comment Author details Author details 1 Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, East Java, 60131, Indonesia 2 General Teaching Hospital Dr. Soetomo, Surabaya, East Java, 60286, Indonesia 3 Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia Siprianus Ugroseno Yudho Bintoro Roles: Conceptualization, Formal Analysis, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Pradana Zaky Romadhon Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Satriyo Dwi Suryantoro Roles: Conceptualization, Formal Analysis, Methodology, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rusdi Zakki Aminy Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Choirina Windradi Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Krisnina Nurul Widiyastuti Roles: Conceptualization, Data Curation, Formal Analysis, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 13 Jan 2022, 10:571 https://doi.org/10.12688/f1000research.53365.2 version 1 Published: 15 Jul 2021, 10:571 https://doi.org/10.12688/f1000research.53365.1 Copyright © 2022 Bintoro SUY et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Bintoro SUY, Romadhon PZ, Suryantoro SD et al. Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.12688/f1000research.53365.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 13 Jan 2022 Revised Views 0 Cite How to cite this report: Gupta R. Reviewer Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.80090.r119664 ) The direct URL for this report is: https://f1000research.com/articles/10-571/v2#referee-response-119664 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Jan 2022 Ritu Gupta , Laboratory Oncology Unit, Dr B.R. Ambedkar IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, Delhi, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.80090.r119664 The authors have summarized the subject ... Continue reading READ ALL The authors have summarized the subject adequately and I have no further comments. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Hemato-Oncology, Genomics, Single-cell sequencing, Flow cytometry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gupta R. Reviewer Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.80090.r119664 ) The direct URL for this report is: https://f1000research.com/articles/10-571/v2#referee-response-119664 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 15 Jul 2021 Views 0 Cite How to cite this report: Gupta R. Reviewer Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.56738.r100511 ) The direct URL for this report is: https://f1000research.com/articles/10-571/v1#referee-response-100511 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 02 Dec 2021 Ritu Gupta , Laboratory Oncology Unit, Dr B.R. Ambedkar IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, Delhi, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.56738.r100511 Priapism is an unusual complication of hematological malignancy with hyperleukocytosis and may be the presenting feature, especially in chronic leukemia as observed in this case. The authors have described the clinical features, investigations, and management of the ... Continue reading READ ALL Priapism is an unusual complication of hematological malignancy with hyperleukocytosis and may be the presenting feature, especially in chronic leukemia as observed in this case. The authors have described the clinical features, investigations, and management of the index case and reviewed the literature on the association of priapism with CML. I have a few comments/suggestions on this manuscript as detailed below: The title is too long and can be abbreviated. Review of hematological malignancies presenting as priapism i.e. including CLL and Acute leukemia would benefit the readers in developing insight on the conditions in which priapism could be the presenting feature. A few references include the following: Johnson et al . (2020 1 ), Ali et al. (2021 2 ) and Gogia et al . (2012 3 ). The meaning of some of the sentences is not clear in several places. The authors may focus on improving the language of the paper. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. James Johnson M, Hallerstrom M, Alnajjar HM, Frederick Johnson T, et al.: Which patients with ischaemic priapism require further investigation for malignancy?. Int J Impot Res . 2020; 32 (2): 195-200 PubMed Abstract | Publisher Full Text 2. Ali EA, Sardar S, Yassin MA: Priapism in lymphoproliferative disorders: A systematic review. Hematol Oncol Stem Cell Ther . 2021. PubMed Abstract | Publisher Full Text 3. Gogia A, Sharma A, Raina V, Gupta R: Priapism as an initial presentation of chronic lymphocytic leukemia. Leuk Lymphoma . 2012; 53 (8): 1638-9 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Hemato-Oncology, Genomics, Single-cell sequencing, Flow cytometry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gupta R. Reviewer Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.56738.r100511 ) The direct URL for this report is: https://f1000research.com/articles/10-571/v1#referee-response-100511 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 10 Dec 2021 Pradana Zaky Romadhon , Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, 60131, Indonesia 10 Dec 2021 Author Response Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. Competing Interests: No competing interests were disclosed. Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. Competing Interests: No competing interests were disclosed. Close Report a concern Author Response 10 Dec 2021 Pradana Zaky Romadhon , Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, 60131, Indonesia 10 Dec 2021 Author Response Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it ... Continue reading Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it will upgrade our manuscript quality. Thanks again. Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it will upgrade our manuscript quality. Thanks again. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 10 Dec 2021 Pradana Zaky Romadhon , Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, 60131, Indonesia 10 Dec 2021 Author Response Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. Competing Interests: No competing interests were disclosed. Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. Competing Interests: No competing interests were disclosed. Close Report a concern Author Response 10 Dec 2021 Pradana Zaky Romadhon , Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, 60131, Indonesia 10 Dec 2021 Author Response Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it ... Continue reading Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it will upgrade our manuscript quality. Thanks again. Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it will upgrade our manuscript quality. Thanks again. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Rajabto W. Reviewer Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.56738.r89693 ) The direct URL for this report is: https://f1000research.com/articles/10-571/v1#referee-response-89693 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 Oct 2021 Wulyo Rajabto , Division of Hematology-Medical Oncology, Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia Approved VIEWS 0 https://doi.org/10.5256/f1000research.56738.r89693 This case report emphasizes the importance of priapism as the rare clinical presentation of chronic myeloid leukemia so that as a clinician we should think if there is patient with priapism the secondary causal is chronic myeloid leukemia. The treatment ... Continue reading READ ALL This case report emphasizes the importance of priapism as the rare clinical presentation of chronic myeloid leukemia so that as a clinician we should think if there is patient with priapism the secondary causal is chronic myeloid leukemia. The treatment of priapism consists of: 1) Local factor by urologist who performs intra cavernous aspiration 2) The systemic factor by hematologist who administers leucapheresis (mechanical and drug eg. Hydroxyurea) and TKIs such as Imatinib. I find the title of this manuscript indeed captivating. Besides describing the priapismus phenomenon in CML, the author also showed to us a comparison study among several previously published cases known worldwide, that I think it is a very interesting plus point. Title: I believe it is very interesting, straightforwardly describes the case. Introduction: I believe it contains concise reasoning why the author brought up this case, emphasizes the rare of similar cases, and interestingly presents one of CML emergencies. Case presentation: The author successfully managed to present the case elaborately along with valid data. Discussion: The author describes the case comprehensively, referred to similar case studies before, from the clinical course to the outcome, as mention on table 1. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: CML, lymphoma, anemia I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Rajabto W. Reviewer Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.56738.r89693 ) The direct URL for this report is: https://f1000research.com/articles/10-571/v1#referee-response-89693 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 15 Jul 2021 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 13 Jan 22 read Version 1 15 Jul 21 read read Wulyo Rajabto , University of Indonesia, Jakarta, Indonesia Ritu Gupta , All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, India Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2022 Gupta R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Jan 2022 | for Version 2 Ritu Gupta , Laboratory Oncology Unit, Dr B.R. Ambedkar IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, Delhi, India 0 Views copyright © 2022 Gupta R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have summarized the subject adequately and I have no further comments. Competing Interests No competing interests were disclosed. Reviewer Expertise Hemato-Oncology, Genomics, Single-cell sequencing, Flow cytometry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Gupta R. Peer Review Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.80090.r119664) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-571/v2#referee-response-119664 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2021 Gupta R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 02 Dec 2021 | for Version 1 Ritu Gupta , Laboratory Oncology Unit, Dr B.R. Ambedkar IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, New Delhi, Delhi, India 0 Views copyright © 2021 Gupta R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (2) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Priapism is an unusual complication of hematological malignancy with hyperleukocytosis and may be the presenting feature, especially in chronic leukemia as observed in this case. The authors have described the clinical features, investigations, and management of the index case and reviewed the literature on the association of priapism with CML. I have a few comments/suggestions on this manuscript as detailed below: The title is too long and can be abbreviated. Review of hematological malignancies presenting as priapism i.e. including CLL and Acute leukemia would benefit the readers in developing insight on the conditions in which priapism could be the presenting feature. A few references include the following: Johnson et al . (2020 1 ), Ali et al. (2021 2 ) and Gogia et al . (2012 3 ). The meaning of some of the sentences is not clear in several places. The authors may focus on improving the language of the paper. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. James Johnson M, Hallerstrom M, Alnajjar HM, Frederick Johnson T, et al.: Which patients with ischaemic priapism require further investigation for malignancy?. Int J Impot Res . 2020; 32 (2): 195-200 PubMed Abstract | Publisher Full Text 2. Ali EA, Sardar S, Yassin MA: Priapism in lymphoproliferative disorders: A systematic review. Hematol Oncol Stem Cell Ther . 2021. PubMed Abstract | Publisher Full Text 3. Gogia A, Sharma A, Raina V, Gupta R: Priapism as an initial presentation of chronic lymphocytic leukemia. Leuk Lymphoma . 2012; 53 (8): 1638-9 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Hemato-Oncology, Genomics, Single-cell sequencing, Flow cytometry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (2) Author Response 10 Dec 2021 Pradana Zaky Romadhon, Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, 60131, Indonesia Firstly, thank you for the detailed review and advice. We have simplified the title and removed unclear sentences then replaced them with more understandable ones. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Author Response 10 Dec 2021 Pradana Zaky Romadhon, Department of Internal Medicine, Airlangga University, Faculty of Medicine, Surabaya, 60131, Indonesia Dear Ritu Gupta, We already just submitted our new version of the manuscript. We also have included one of the references recommended by you in our discussion. Hope it will upgrade our manuscript quality. Thanks again. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Gupta R. Peer Review Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.56738.r100511) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-571/v1#referee-response-100511 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2021 Rajabto W. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 Oct 2021 | for Version 1 Wulyo Rajabto , Division of Hematology-Medical Oncology, Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia 0 Views copyright © 2021 Rajabto W. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case report emphasizes the importance of priapism as the rare clinical presentation of chronic myeloid leukemia so that as a clinician we should think if there is patient with priapism the secondary causal is chronic myeloid leukemia. The treatment of priapism consists of: 1) Local factor by urologist who performs intra cavernous aspiration 2) The systemic factor by hematologist who administers leucapheresis (mechanical and drug eg. Hydroxyurea) and TKIs such as Imatinib. I find the title of this manuscript indeed captivating. Besides describing the priapismus phenomenon in CML, the author also showed to us a comparison study among several previously published cases known worldwide, that I think it is a very interesting plus point. Title: I believe it is very interesting, straightforwardly describes the case. Introduction: I believe it contains concise reasoning why the author brought up this case, emphasizes the rare of similar cases, and interestingly presents one of CML emergencies. Case presentation: The author successfully managed to present the case elaborately along with valid data. Discussion: The author describes the case comprehensively, referred to similar case studies before, from the clinical course to the outcome, as mention on table 1. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise CML, lymphoma, anemia I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Rajabto W. Peer Review Report For: Case Report: Priapism as The Clinical Presenting Feature of Chronic Myeloid Leukemia: Case Report and 20-Year Literature Review [version 2; peer review: 2 approved] . F1000Research 2022, 10 :571 ( https://doi.org/10.5256/f1000research.56738.r89693) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-571/v1#referee-response-89693 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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