Acute myeloid leukemia (AML) is a heterogeneous hematologic malignancy with diverse morphologic and immunophenotypic subtypes. The RAM (rapidly maturing) phenotype is a rare and poorly characterized variant, initially described in pediatric acute leukemia, but has also been identified in older adults (Wells et al., 2018). It is typically defined by CD45^dim, CD34–, CD117+, CD33++, and aberrant CD7 expression, with aggressive clinical behavior and poor prognosis (Nguyen et al., 2021). Here, we present a case of elderly-onset AML with RAM-like immunophenotypic features.

A 81-year-old female presented with pancytopenia and recurrent subdural hemorrhages. Flow cytometry revealed CD45^dim, CD34–, CD117+, CD33++, and aberrant CD7+ blasts, consistent with RAM-like AML. Cytogenetic analysis showed no recurrent AML-defining translocations by FISH. Comprehensive molecular testing, including FLT3, NPM1, and CEBPA, was negative. Clinical frailty assessment demonstrated a high CIRS score, limiting intensive treatment options.

Bone marrow examination confirmed AML with RAM-like immunophenotype. Given the patient’s age, comorbidities, and recurrent intracranial hemorrhages, intensive induction chemotherapy was contraindicated. Supportive care and hypomethylating agent-based therapy were considered but deferred due to poor functional status and ongoing hemorrhagic risk. The patient remained under best supportive care, including transfusions and infection prophylaxis. Prognosis was explained to the family as extremely poor, consistent with published literature (Al-Kershi et al., 2023).

RAM-like AML represents a high-risk immunophenotypic subset, characterized by treatment resistance and inferior outcomes (Wells et al., 2018). Most reported cases occur in children; however, adult and elderly cases are being increasingly recognized (Nguyen et al., 2021). This case highlights the diagnostic challenge and limited therapeutic options in elderly patients, particularly when performance status and comorbidities preclude intensive therapy. Early recognition through flow cytometry is essential for risk stratification and counseling.

We report an elderly female with AML exhibiting RAM-like phenotype, an aggressive and rare immunophenotypic variant. Awareness of this entity is important for hematologists, as it informs prognosis and guides therapeutic decision-making, even when curative approaches are not feasible.