LEUKEMIALEUKEMIA

T.J. , 25 yrs/old, maleT.J. , 25 yrs/old, male

ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA

October 17, 2008October 17, 2008

January 15, 2009January 15, 2009

(+) palpable lymph nodes(+) palpable lymph nodesGlobular abdomenGlobular abdomen

Pain at left legPain at left leg

LEUKEMIA OVERVIEWLEUKEMIA OVERVIEW

Uncontrolled Uncontrolled production of WBC production of WBC caused by cancerous caused by cancerous mutation of mutation of myelogenous or myelogenous or lymphogenous celllymphogenous cell

CLASSIFIED BY:CLASSIFIED BY:

1.1. Onset Onset Acute – rapid onset of immature, Acute – rapid onset of immature,

non functional cellsnon functional cells Chronic – gradual onset of mature, Chronic – gradual onset of mature,

functioning (reduced) cellsfunctioning (reduced) cells

2. Predominant cell2. Predominant cell MyelogenousMyelogenous LymphogenousLymphogenous

LABORATORY AND LABORATORY AND DIAGNOSTICSDIAGNOSTICS

                                                                             

01/1501/15 01/1601/16 01/1901/19 1/211/21

HgbHgb 6.96.9 10.310.3 10.610.6 1010

HctHct 19.919.9 3030 32.232.2 30.530.5

RBCRBC 2.042.04 3.223.22 3.443.44 3.083.08

WBCWBC 55005500 59005900 49604960 38003800

Diff. Ct.Diff. Ct.

NeutrophilsNeutrophils 7979 8686 7979 4141

LymphocyteLymphocytess

1212 77 1111 4848

EosinophilsEosinophils 11 22 11 22

MonocytesMonocytes 99 77 99 99

Platelet Ct.Platelet Ct. 53,00053,000 56,00056,000 51,00051,000 65,00065,000

NECK CT-SCAN

 

 INTERVAL APPEARANCE OF SLIGHTLY ENLARGED LYMPH NODE IN THE INTERNAL JUGULAR CHAIN (LEVEL II) ON BOTH SIDES. 

        THERE WAS RELATIVELY MORE BIGGER SUBCENTIMETER LYMPH NODES ON BOTH SIDES OF THE NECK AT THIS TIME. 

BONE MARROW ASPIRATION/BIOPSYBONE MARROW ASPIRATION/BIOPSY

The doctor removes some bone marrow The doctor removes some bone marrow from the hipbone or another large bone. A from the hipbone or another large bone. A pathologist examines the sample under a pathologist examines the sample under a microscopemicroscope. The removal of . The removal of tissuetissue to look to look for cancer cells is called a biopsy. A for cancer cells is called a biopsy. A biopsy is the only sure way to know biopsy is the only sure way to know whether leukemia cells are in the bone whether leukemia cells are in the bone marrow. marrow.

PHYSIOLOGY OF WBCPHYSIOLOGY OF WBCmobile units of body’s protective mobile units of body’s protective

systemsystemFormed partially in bone marrow Formed partially in bone marrow

(granulocytes and few lymphocytes) (granulocytes and few lymphocytes) and partially in lymph nodes and partially in lymph nodes

(lymphocytes and plasma cells)(lymphocytes and plasma cells)

GENESIS OF WBC

Pluripotential Stem cell

Myeloblast Lymphoblast

promyeloblast Prolymphoblast

Lymphoid stem cell

Neutrophil myeloblast

Eosinophil myeloblast

Basophil myeloblast

Young neutro m. Eosinophil

metamyelocyte

P. basophilsBand neutrophilmyelocyte

P. eosinophils

Polymorphonuclearneutrophils

Dendritic cell

B lymphocyte

T lymphocyte

Natural killer cell

Monocyte

Plasma cells

ActivatedT cell

MAIN FUNCTIONMAIN FUNCTION

PHAGOCYTOSIS:PHAGOCYTOSIS:

- cellular ingestion of offending - cellular ingestion of offending agent agent

- highly selective- highly selective

Occurs:Occurs:

1.1. Most natural structures in tissues are Most natural structures in tissues are smooth surfaces, if it is rough smooth surfaces, if it is rough phagocytosis occursphagocytosis occurs

2. Protective protein coats normal cells and 2. Protective protein coats normal cells and tissue, dead tissue and foreign materials tissue, dead tissue and foreign materials has nonehas none

3. Presence of antibodies3. Presence of antibodies

- adhere to bacterial membrane- adhere to bacterial membrane

- antibody molecule + C3 product of - antibody molecule + C3 product of complement cascade = attaches to complement cascade = attaches to bacterial membrane then are phagocytize bacterial membrane then are phagocytize

OpsonisationOpsonisation

Neutrophils – attaches to bacteria Neutrophils – attaches to bacteria projects pseudopodia enclosed projects pseudopodia enclosed chamber invaginates form chamber invaginates form phagosomesphagosomes

- can phagocytize 3 – 20 bacteria - can phagocytize 3 – 20 bacteria before it inactivates and diebefore it inactivates and die

Macrophages – powerful phagocytesMacrophages – powerful phagocytes

- can phagocytized 100 bacteria - can phagocytized 100 bacteria and large particlesand large particles

- has lipases that digest thick lipid - has lipases that digest thick lipid

lipid membranes of some bacteria lipid membranes of some bacteria and virusesand viruses

Digestion of phagosomes by fusion with Digestion of phagosomes by fusion with lysosomes (proteolytic enzymes) to form lysosomes (proteolytic enzymes) to form digestive vesicles for digestiondigestive vesicles for digestion

Contains bactericidal agents such as: Contains bactericidal agents such as: oxidizing agents by perixosome enzymeoxidizing agents by perixosome enzyme

Super oxide, hydrogen peroxide, hydroxyl Super oxide, hydrogen peroxide, hydroxyl ions, hypochlorite ions, hypochlorite

Monocytes- macrophages systemMonocytes- macrophages system

Generalized phagocytic system in all Generalized phagocytic system in all tissuestissues

Composed of monocytes, macrophages Composed of monocytes, macrophages (fixed tissue macrophages and mobile (fixed tissue macrophages and mobile macrophages) and specialized endothelial macrophages) and specialized endothelial cells in bone marrow, spleen, lymph nodescells in bone marrow, spleen, lymph nodes

Also known as Reticuloendothelial SystemAlso known as Reticuloendothelial SystemSkinSkinLymph nodes – no particular matter enters Lymph nodes – no particular matter enters

tissue can be absorbed directly through tissue can be absorbed directly through capillary membrane to the bloodcapillary membrane to the blood

- if not destroyed, enters lymph - if not destroyed, enters lymph then to lymph nodesthen to lymph nodes

Afferent lymphatics nodal medullary Afferent lymphatics nodal medullary sinuses sinuses hilushilus efferent lymphaticsefferent lymphatics

venous bloodvenous blood

- particle is trap and engulf by - particle is trap and engulf by macrophages in the meshwork of sinusesmacrophages in the meshwork of sinuses

Lungs – macrophages at alveolar wallsLungs – macrophages at alveolar walls

- if particle is not digestible forms - if particle is not digestible forms giant cell capsule and slowly dissolvesgiant cell capsule and slowly dissolves

Liver sinusoids – kuppfer cellsLiver sinusoids – kuppfer cells

- forms effective particulate filtration- forms effective particulate filtration

Spleen and Bone marrowSpleen and Bone marrow

small arterysmall artery splenic pulp splenic pulp cords cords of red pulp of red pulp trabeculae trabeculae circulation circulation

- phagocytizing debris in blood (old and - phagocytizing debris in blood (old and abnormal cell)abnormal cell)

DEFENSE AGAINST INFECTIONDEFENSE AGAINST INFECTION

FIRST LINE OF DEFENSE:FIRST LINE OF DEFENSE:TISSUE MACROPHAGESTISSUE MACROPHAGESenlargement of sessile macrophageenlargement of sessile macrophage

break loose from attachment break loose from attachment

mobilized to area of injurymobilized to area of injury

phagocytized bacteria or virusesphagocytized bacteria or viruses

SECOND LINE OF SECOND LINE OF DEFENSE:DEFENSE:

NEUTROPHILSNEUTROPHILS

- invasion of - invasion of large number of large number of neutrophils at the neutrophils at the injured areainjured area

Initiation of the following Initiation of the following reactions:reactions:

1.1. MarginationMargination

2.2. DiapedesisDiapedesis

3.3. ChemotaxisChemotaxis

THIRD LINE OF DEFENSE:THIRD LINE OF DEFENSE:

MONOCYTESMONOCYTES

- immature cells in the blood that - immature cells in the blood that becomes macrophages as they swell and becomes macrophages as they swell and transport into tissue transport into tissue

- however number of monocytes in - however number of monocytes in blood are low and storage pool in marrow blood are low and storage pool in marrow is less than neutrophilsis less than neutrophils

- needs 8 hours or more to mature - needs 8 hours or more to mature

FOURTH LINE OF DEFENSE:FOURTH LINE OF DEFENSE:

INCREASED PRODUCTION OF INCREASED PRODUCTION OF GRANULOCYTES AND MONOCYTESGRANULOCYTES AND MONOCYTES

- stimulation of granulocytic and - stimulation of granulocytic and monocytic progenitor cellsmonocytic progenitor cells

- takes 3 to 4 days before maturation - takes 3 to 4 days before maturation of granulocytes and monocytesof granulocytes and monocytes

FEEDBACK CONTROL FEEDBACK CONTROL

INFLAMMATION INFLAMMATION TNF, IL-1TNF, IL-1

TNF, IL-1TNF, IL-1 endothelial cells,endothelial cells,

GMCSF, GCSFGMCSF, GCSF fibroblast, fibroblast, MCSFMCSFlymphocyteslymphocytes

Bone marrowBone marrow

granulocytes, monocytes, macrophagesgranulocytes, monocytes, macrophages

EOSINOPHILS – weak phagocytesEOSINOPHILS – weak phagocytes

- kills parasites by:- kills parasites by:

1.1. Releasing hydrolytic enzymes from their Releasing hydrolytic enzymes from their granules w/c are modified lysosomesgranules w/c are modified lysosomes

2.2. Releasing of high reactive forms of Releasing of high reactive forms of oxygenoxygen

3.3. Releasing from granules larvacidal Releasing from granules larvacidal polypeptidepolypeptide

- detoxify inflammation- - detoxify inflammation- inducing inducing substancesinducing inducing substances

BASOPHILS – liberate heparin to blood BASOPHILS – liberate heparin to blood - release histamine, bradykinin - release histamine, bradykinin

and serotoninand serotonin

- basophils + IgE - basophils + IgE antigen reacts to antibody antigen reacts to antibody rupture of rupture of mast cells and basophils = release of mast cells and basophils = release of substances of anaphylaxissubstances of anaphylaxis

PathophysiologyPathophysiology

Blocks differentiation Continuous accumulation

Inc amount of cells

**Immature cells

“Crowd out” cellular proliferation of othercells

Erythrocytic stem cells

Megakaryocitic stem cells

Dec. RBC

Anemia

Fatigue

Dec. platelet

Bleeding

hypermatabolism

Weight lossspleen liver bone

spleenomegaly

hepatomegaly Bone pain

Fracture

FAMILIAL HISTORY(+) mother’s side, aunt

Myelobalst transformation

Non-functioning cells

Decrease defense against infection and injury

Fever

Nursing ProblemsNursing Problems

Pain Pain

- pain at left leg- pain at left leg

- bone pain cause by infiltration of leukemic - bone pain cause by infiltration of leukemic at bone areasat bone areas

High risk for infectionHigh risk for infection

- low WBC count, non functional cells- low WBC count, non functional cells

High risk for bleedingHigh risk for bleeding

- low platelet count- low platelet countFatigueFatigue

- low RBC count, hypermetabolism- low RBC count, hypermetabolism

BibliographyBibliography

T-Cell T-Cell Therapy of Therapy of LeukemiaLeukemia

THANK YOU!THANK YOU!