acute leukemia

Welcometo

Clinical Meeting

Dr. Maimuna SayeedResident, Phase-A

Paediatric Gastroenterology & NutritionBSMMU

Particulars of the Patient

Name: Md. HuzaifaAge: 6 yearsSex: MaleAddress: GazipurDate of admission: 29/10/2016Date of examination: 30/10/2016Informant: Mother

Presenting Complaints

1. Fever for 2 months2. Multiple nodular swelling in different parts of

body for 2 months3. Swelling of left testis for 2 months4. Gradual pallor for 1 month5. Swelling of right eye for 7 days

History of Present Illness

According to the statement of the informant mother, her child was reasonably well 2 months back. Then he developed fever, which was initially low grade, then became high grade, continued in nature, not associated with chills and rigor. Highest recorded temperature was 104°F and fever was not subsided by taking oral antibiotics. Mother noticed multiple nodular painless swelling in both side of neck and groin for same duration. At the same time he also developed painless swelling of left testis.

History of Present Illness (contd.)

Mother also noticed progressive pallor for last one month. She also mentioned about gradual swelling of his right eye for 7 days.There was no history of headache, convulsion, blurring of vision, cough, respiratory distress, gum swelling, bleeding manifestations, weight loss, exposure to ionizing radiation or contact with known TB patient.

History of Present Illness (contd.)

He was treated by different physician with oral antibiotics. Later he got admitted to Dhaka Shishu Hospital and had 4 units of blood transfusion. Due to financial constrains they took discharge from there. Then after one week he got admitted into BSMMU for further evaluation and management.

Birth HistoryHe was delivered by LUCS at term in a private

hospital with average birth weight without any complications. His antenatal, natal and post-natal period was uneventful.

Developmental HistoryHe is developmentally age-appropriate.

History of past illnessNothing significant.

Feeding HistoryHe was on exclusive breast feeding until his 6

months of age. Then complimentary feeding was started. Now he is on family diet.

Immunization HistoryHe is immunized as per EPI schedule.

Family HistoryHe is the 2nd issues of non-consanguineous

parents. No other family member has similar types of illness.

Socio-economic HistoryHe belongs to a middle class family . His father is a

businessman and mother is a housewife. Their average monthly income is around 20,000 tk.

Treatment HistoryHe took oral antibiotics & syrup paracetamol during

this period of illness. He also received blood transfusion 4 times.

Physical Examination

General Examination

Appearance: Ill-looking, swelling of right eyeModerately paleJaundice: AbsentCyanosis: AbsentClubbing: AbsentKoilonychia: AbsentEdema: AbsentDehydration: AbsentSkin Survey: BCG mark present, there is no bleeding

manifestations.

General Examination (contd.)

Lymphadenopathy:oSubmandibular oAnterior and posterior cervical

chain (both side)oAxillary lymph nodes(both side)oInguinal lymph nodes(both side)

Size: 2cm × 2cm (Submandibular)Discrete Non-tender Firm in consistencyNot fixed with underlying structure &

overlying skin No discharging sinus


Bony Tenderness: AbsentSigns of Meningeal Irritation:

AbsentExamination of Eye: Proptosis

of both eyes (right>left)Examination of Ear, Nose and

Throat: Normal


Vital Signs• Temperature : 98°F• Pulse: 96 beats/min• Resp. Rate: 28 breaths/min• Blood Pressure: 90/60 mm Hg (SBP lies below 50th

percentile & DBP lies between 50th - 90th percentile)

Anthropometry

• Weight: 17kg (lies between 5th and 10th percentile)

Anthropometry • Height: 117 cm (lies on 50th-75th percentile)

Systemic Examination

Haemopoietic System

Moderately paleBony Tenderness: AbsentSkin survey: Normal.Oral Cavity: Healthy, no gum hypertrophy, no sign of

bleeding manifestation.Lymph node: Submandibular, bilateral anterior and

posterior cervical lymph nodes of both sides are palpable & largest one measuring about 2cm × 2cm in size and all are discrete, non-tender, firm in consistency, not fixed with underlying structure & overlying skin & there is no discharging sinus.

Haemopoietic System (contd.)

Liver:Palpable 6 cm from the right costal margin along the

midclavicular lineSurface - smoothConsistency - firmMargin - sharpNon-tenderUpper border of liver dullness lies on the right 5th ICS.

Haemopoietic System (contd.)

Spleen:Enlarged 8 cm from the left costal margin along it’s long axisSurface - smoothConsistency - firmNon-tenderSplenic notch - presentFinger insinuation test - negative

Alimentary System

Oral Cavity:HealthyNo gum hypertrophyNo bleeding manifestations.

Abdomen proper:Inspection:

Size & shape: normalUmbilicus: Centrally Placed , invertedNo visible mass, no scar mark.

Alimentary System (contd.)

Palpation:Superficial palpation:

Abdomen is soft, non-tender.Deep Palpation:

Liver: Enlarged 6 cm from the right costal margin . surface smooth, Non tender.Spleen: Enlarged 8 cm from the left costal margin along it’s long axis.

Alimentary System (contd.)

Percussion:Percussion note: TympanicShifting Dullness : Absent.

Auscultation: Bowel sound : Present

Genitourinary System:

Kidneys: Not ballotableUrinary Bladder: Not palpableHernial Orifice: IntactGenitalia: Male typeTestes:

size: left sided testicular swelling was present

temperature: not raisedtenderness: absentconsistency: firm to hardsurface: smooth, not attached

to skin

Respiratory System Examination

Inspection:Respiratory Rate: 28 breaths/minShape of the chest: NormalChest Movement: Symmetrical

Palpation:Trachea: Centrally PlacedChest Expansibility: Symmetrical

Percussion:Percussion Note: Resonant all over the chest.

Auscultation:Breath Sound: VesicularNo Added sound

Cardiovascular system Examination

Inspection:No visible pulsation.

Palpation:Apex Beat: Located in the Left 5th ICS , just medial to the midclavicular Line.Thrill : AbsentLeft Parasternal Heave: Absent.Palpable P2 : Absent

Auscultation:Heart Sound: 1st and 2nd heart sounds are audible in all the four areas.Murmur : Absent

Nervous System Examination

Higher Psychic Function:Appearance : Ill-looking.

Examination of motor system:Bulk of the Muscle: NormalTone of the Muscle: Normal Power of the Muscle: NormalSuperficial Reflexes: IntactDeep Reflexes : Intact

Examination of the Sensory system:Intact

Examination of cranial nerves:Intact

Locomotor System Examination

LOOK: No sign of arthritis, no visible deformity,No muscle wasting.

FEEL: Local temperature- Not raisedTenderness- Absent.

MOVE: Not restricted.

Salient Feature

Md. Huzaifa, 6 years old boy, 2nd issues of non-consanguineous parents, got admitted with the complaints of fever for 2 months, which was initially low grade, then became high grade, continued in nature, not associated with chills and rigor, not responding to antibiotics. He developed multiple nodular painless swelling in both side of neck and groin region and left sided painless testicular swelling for same duration. He also developed progressive pallor for last 1 month and swelling of right eye for 7 days.

Salient Feature (contd.)

There was no history of headache, convulsion, blurring of vision, cough, respiratory distress, gum swelling, bleeding manifestations, exposure to ionizing radiation or contact with any known TB patient.

He was treated with oral antibiotics and got 4 units of blood transfusion.

Salient Feature (contd.)

On general examination, the patient was ill-looking, moderately pale, afebrile, bilateral proptosis present (right>left), bony tenderness was absent, generalized lymphadenopathy present. Vitals were within normal limit. Anthropometry within centile chart. On systemic examination, patient had hepatosplenomegaly & left sided testicular swelling. There was no bleeding manifestations, or gum hypertrophy. Examination of other systems revealed nothing abnormality.

PROVISIONAL DIAGNOSIS

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Provisional Diagnosis

Acute Leukemia (Acute Myeloid Leukemia)

Differential Diagnosis

Acute Lymphoblastic Leukemia

Acute Myeloid Leukemia

Points in Favour Points against

H/O Fever Gradual pallorO/E Moderately pale in spite of

getting blood transfusion Generalized

Lymphadenopathy Hepatosplenomegaly Proptosis

No bleeding manifestation No gum hypertrophy No chloroma

Acute Lymphoblastic Leukemia

Points in Favour Points against

H/O Fever Gradual pallorO/E Moderately pale in spite of

getting blood transfusion Generalized

Lymphadenopathy Hepatosplenomegaly Testicular swelling

Proptosis

Investigations

CBCHemoglobin 8.4 gm/dlTC of WBC 117.69 x 109/LDifferential counts:

Neutrophil 05%Lymphocyte 15%Eosinophil 0.1%Basophil 00%Monocyte 00%Blast 80%

Investigations (contd.)

RBC PanelRBC count 3.12 x 1012/LHCT 27.2%MCV 87.2 fLMCH 26.9 pgMCHC 30.9 g/dlRDW-CV 16%

Platelet 36 x 109/L


Bone Marrow Study: Gross Description:

Cellularity HypercellularMyeloid : Erythroid ratio IncreasedErythropoiesis DepressedGranulopoiesis DepressedMegakaryocytes Scanty

Bone Marrow Differentials:Lymphoblast 80%

Diagnosis: Acute Lymphoblastic Leukemia (ALL-L2)


ImmunophenotypingCd3 0.34%Cd5 3.75%Cd7 4.82%Cd10 87.87%Cd19 89.99%

Cd13 1.12%Cd33 3.88%Cd34 50.80%

cCd79a 90.70%HLADR 93.25%cMPO 1.13%Cd117 0.11%

Comment: Acute Lymphoblastic Leukemia (B cell lineage)


S. LDH 542 U/LS. Uric acid 3.3mg/dlS. Calcium 8.2mg/dlS. Inorganic PO4 5.1mg/dlS. Electrolytes:

Sodium 140mmol/lPotassium 4.1mmol/lChloride 105mmo/lTCO2 28mmol/l


S. ALT 40U/LProthrombin time 14.7secAPTT 28.2secS. Creatinine 0.51mg/dlRBS 5.8 mmol/LHBsAg NegativeBlood Grouping A+veCSF study Negative for malignant cell, CNS-1


Chest X-ray P/A view Normal

Final Diagnosis

Acute Lymphoblastic Leukemia (B-cell lineage) with Hyperleukocytosis

Treatment

Counselling.Supportive :

Diet – Neutropenic.Adequate hydration (2 ltr/sq.m/day) with NaHCO3Nystatin oral dropChlorohexidine mouth washAcriflavin hip bath.

Tab. Allopurinol Tab. ParacetamolSyp. Antacid

Treatment (contd.)

Specific Treatment Protocol based Multiagent Chemotherapy (UK ALL 2003 - Regimen B)

30.10.16 02.11.16



Platelet <10 x 109/L



Platelet <10 x 109/L

Follow up on 03/11/16 (day-6)Subjective Objective Assessment Plan

No new complaints

•Ill looking•mildly pale•Proptosis (right>left)•Oral cavity: Healthy•Pulse: 88 b/m•BP: 80/60 mmHg•RR: 24/min•Temp: 98○ F• G. Lymphadenopathy•Liver: 5cm palpable•Spleen: 7cm palpable•Testicular swelling (left)•Bowel : Moved•U/O: 3ml/kg/hr

Static Start of chemotherapy

Follow up on 07/11/16 (day-10)Subjective Objective Assessment Plan

No new complaints (IR D3)

•Ill looking•mildly pale•Proptosis (right)•Oral cavity: Healthy•Pulse: 82 b/m•BP: 80/50 mmHg•RR: 20/min•Temp: 98○ F• G. Lymphadenopathy•Liver: 4cm palpable•Spleen: 6cm palpable•Testicular swelling (left)•Bowel : Moved•U/O: 3.4ml/kg/hr

Improving Continue Chemotherapy

Repeat CBC & biochemical work up

T H A N K Y O U

acute leukemia

Health & Medicine