NYU Medicine Grand Rounds Clinical

Vignette

Maryann Kwa, MDPGY-2

January 12, 2011

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

The patient is a 39-year-old man presenting with fever, chills, and a non-productive cough for one week.

Chief Complaint

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• The patient was in his usual state of good health until six months prior to admission, when he began to note a gradual weight loss.

• One week prior to admission, he started having fevers up to 101˚.

History of Present Illness

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• The fevers were accompanied by chills, night sweats, and an intermittent dry cough.

• Given concern over his symptoms, he presented to the Bellevue Hospital emergency room.

History of Present Illness

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Additional History• Past Medical History:

• None

• Past Surgical History:• Appendectomy at age 16

• Social History:• He was born in New York. He works as a cook in a restaurant. He denied tobacco, alcohol or drug use.

• Family History:• Mother, alive at age 65, with breast cancer

•Allergies: • No Known Drug Allergies

Medications:• Multivitamin daily

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Physical Examination

• General: Well-developed young male who appeared fatigued and in no acute distress

• Vital Signs: T: 100.9 BP: 120/80 HR: 90 RR: 16 and O2 sat: 95% room air

• Abdomen: Palpable spleen tip

• Extremities: Trace lower extremity edema bilaterally to knees

• Lymph nodes: Shoddy 1 centimeter lymph nodes palpated in bilateral axilla and right inguinal region

• The remainder of the physical exam was normalUNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Laboratory Findings

• CBC: • Hemoglobin/Hematocrit 9.0/27

• MCV 87 • Platelets 256

• White blood cell count 11.0

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Laboratory Findings

• White blood cell count differential:

Neutrophils 56% (44-70) with 4% bands (2-8)Lymphocytes 16% (20-45)Monocytes 4% (2-10)Basophils 7% (0-2)Eosinophils 1% (1-4)Metamyelocytes 2% (<=0)Myelocytes 4% (<=0)Promyelocytes 2% (<=0)Blasts 3% (<=0)

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Laboratory Findings

• Basic Metabolic panel: Creatinine 1.3 • Remainder of basic was within normal limits

• Hepatic panel: within normal limits

• International normalized ratio: within normal limits

• Partial thromboplastin time: within normal limits

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Acute myeloid leukemia, versus chronic myeloid leukemia with blast crisis, versus lymphoma

Differential Diagnosis

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Additional Laboratory Studies

• Lactate dehydrogenase: 502 (110-225 U/L)

• Haptoglobin: 435 (30-200 mg/dL) • Reticulocyte %: 1.99 (0.5-1.5)

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Additional Laboratory Studies

• Iron: 50 (42-146 ug/dL)

• Total iron-binding capacity: 310 (250-450 ug/dL)

• Ferritin: 650 (22-322 ng/mL)

• Peripheral Smear: numerous immature white blood cells including blasts, normal red blood cells and platelets

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

CAT Scan Chest

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• Hospital Day 1:– Bone marrow biopsy was performed.– Flow cytometry and cytogenetics were sent.

Hospital Course

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• Hospital Days 2 and 3:– Bone marrow biopsy showed hypercellular marrow with 20% blasts.

– Immunophenotyping showed immature cells positive for CD13, CD 33, CD 34, CD 117 and myeloperoxidase.

– Cytogenetics revealed translocation between chromosomes 8 and 21 [t(8;21)].

Hospital Course

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21

Revised Working Diagnosis

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• Hospital Day 4:– The patient was started on induction chemotherapy with 7 days of cytarabine and 3 days of idarubicin (“7+3” regimen).

• Hospital Day 15:– The patient tolerated chemotherapy well and was discharged home with outpatient oncology follow-up.

Hospital Course

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• A repeat bone marrow biopsy showed complete remission after induction chemotherapy.

• The patient is currently awaiting consolidation therapy.

Outpatient Course

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

• Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21, responsive to induction chemotherapy, now in complete remission.

Final Diagnosis

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS