1 st admission
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Transcript 1 st admission
INTERHOSPITAL
CONFERENCE
17 NOVEMBER 2009
10 years old boy
Prolong fever, arthritis
PATIENT DATA
ผู้ป่วยเด็กชายไทย อายุ 10 ปี
ทีอ่ ยู่ อาเภอเมือง จังหวัดกาฬสิ นธุ์
Chief complaint
ไข้ สูง ปวดข้ อ 1
สั ปดาห์ ก่ อนมาโรงพยาบาล
PRESENT ILLNESS
1 เดือนก่ อน มาด้ วยไข้
7 วัน ปวดข้ อ ข้ อบวม
SEM at LUPSB, liver 4cm below RCM
Lt wrist, Lt knee and ankle then Rt ankle arthritis
(migratory polyarthritis)
INVESTIGATION 1 เดือนก่อน
CBC: Hct 28.6%, Hb 9 g/dl, corrected WBC 9,600, N 37%, L 43%,
M 18%, NRC 153/100 WBC, plt 117,000
MCV 72.9, MCH 22.9, MCHC 31.4, RDW 20.8
ESR 82 mm/hr, ANA-, ASO positive 1:1, RF -, CRP + 1:64,
Melioid titer 1:40, H/C no growth, PPD CXR: mild cardiomegaly
EKG: NSR, HR 120/min, QRS axis 750, PR 0.12 sec, QTc 0.38 sec,
borderline LVH
Echocardiogram: EF 76.8%, mild LV enlargement, trivial MR
Dx: acute rheumatic fever: 1 major (poly arthritis), 2 minor ( fever,
ESR, CRP), + evidence Strep infection (ASO+)
Rx: cefotaxime x 8 d, amoxy+clavulanic acid x 6d,
ASA gr V (90mkd)
Severe joint pain, pain score= 10 : suspected malignancy/ JRA
Brufen, tramol, MST, morphine syrup prn
Prednisolone 2 MKD x 2 wk
LDH 2,476 U/L uric acid 6.3 mg/dl, ESR 135 mm/hr, CRP 1:16,
Coomb’s test –, ANA-, RF-, UA normal
eye exam: no uveitis
BMA: inadequate
BM biopsy: fragment of cartilage, no bone marrow tissue seen
Film bone survey: multiloculated cystic lesion at distal
femur, no osteolytic lesion, suspected benign condition,
No malignancy condition
Bone scan: ?
Ultrasound abdomen: hepatomegaly
of Lt
PRESENT ILLNESS
1
สั ปดาห์ ก่อนมาโรงพยาบาล มีไข้ สูง ส่ วนใหญ่ เป็ นไข้ กลางคืน
ปวดเมื่อยต้ นขา 2 ข้ าง ปวดข้ อศอก ทั้ง 2 ข้ าง ข้ อมือ ข้ อนิว้ มือ ข้ อ
เข่ าขวา ไม่ ไอ ไม่ หอบ ปวดศีรษะเล็กน้ อย ปัสสาวะอุจจาระปกติ
ไม่ มีนา้ หนักลด รับประทานอาหารได้
2 วัน ก่ อนมา ไข้ ตลอดวัน ปวดข้ อมากขึน
้ ปวดสะโพก 2 ข้ าง เดิน
ลาบาก
PAST HISTORY
มีเลือดกาเดาไหลเป็ นๆหายๆ
(ตั้งแต่ อายุ 3-4 ปี ปี ละ 3-4 ครั้ง)
7 เดือนก่ อน มาด้ วยไข้ 2 เดือน เบื่ออาหาร อ่ อนเพลีย ท้ องโตขึน
้ ซีดลง
นา้ หนักลดลง 2 กิโลกรัม ใน 1 เดือน
ตรวจร่ างกาย พบซีด ม้ ามโต 10 cm below LCM,
CBC: pancytopenia
BMA: erythroid hyperplasia, no blast
BM biopsy: bony tissue with paucity number of
hematopoietic cells without evidence of leukemia
Lymph node biopsy at inguinal: reactive lymphoid hyperplasia
PAST HISTORY
CT abdomen: diffuse splenomegaly
Splenectomy:
diffuse sinusoidal hemangiomatosis with
extramedullary hemopoeisis
EBV Ig M +, IgG+, CMV IgM-, IgG+
Antibiotic
17 days
Hb typing: Homozygous Hb E
PAST HISTORY
จากนั้นมา follow up ทุก 1 เดือน
มีไข้ บางครั้ง เลือดกาเดาไหล
เล็กน้ อย admit 1 ครั้ง เมื่อ 4 เดือนก่อน x 2 วัน
Hct 29% WBC, platelet ปกติ
ได้ รับ folic, MTV, zyrtec
Family history
มารดาเป็ นโรคหอบหืด
มีญาติทางบิดาเป็ นโรคเลือด (ไม่ ทราบว่ าเป็ นโรคอะไร)
ปฏิเสธประวัติมะเร็ งในครอบครั ว
PHYSICAL EXAMINATION
Vital signs:
BT 39.70 C
BP 110/70 mmHg
PR 112/min RR 22/min
BW 23 kg (P3-10)
Ht 130 cm (P25)
GA: A boy, fully consciousness, well co-operate
HEENT: mild pale conjunctiva , anicteric sclera
pharynx and tonsils: not injected
Rt cervical lymph node 0.5 cm
PHYSICAL EXAMINATION
Heart
: systolic ejection murmur gr II at LPSB
Lungs : normal and equal breath sound, no adventitious sound
Abdomen: soft, liver 3 cm below RCM
Extremities: no edema
Tender and swelling of bilateral elbow, wrist, 4th, 5th MCP, Lt 2nd,
5th MCP, Rt knee joint
PROBLEM LISTS
Prolong fever
Polyarthritis
Anemia
Hepatomegaly
SEM gr II
S/P splenectomy
Homozygous HbE
DDX
Infection:
TB, virus (EBV, CMV),
Bacteria, fungus
Connective tissue disease: JRA, SLE
Malignancy: acute leukemia,
lymphoma
IAHS
LCH
INVESTIGATION
INVESTIGATION
CBC: Hb 10.2 g/dL, Hct 31%, WBC corrected 4,900
N 45%, L 36%, M 18%, E 8%,
NRC 91/100 WBC, Platelet 131,000
MCV 85.7 fl, MCH 28.2 pg, MCHC 32.9 g/dL
BUN 5 mg/dL, Cr 0.4 mg/dL, Uric acid 3.4 mg/dL
Na 139, K 3,8, Cl 97, CO2 29 mmol/L, Ca 8.9, Mg 2, P 4 mg/dL
Albumin 2.4 g/dL, AST 54 U/L, ALT 37 U/L. ALP 520 U/L
Hemoculture; no growth
UA : pH 5.5 ,sp.gr. 1.025, wbc 1-2 , rbc 0-1
ESR : 75 mm/hr
INVESTIGATION
LDH 542 U/L
Ferritin 3,840 ng/ ml
B-HCG 1.11 mIU/ml, AFP 3.08 IU/ml
ASO-, CRP-, Melioid 1:20
Bone marrow
aspiration
Multiple radiolucency lesions
Ultrasound whole abdomen
:diffuse hepatomegaly
BMA: inadequate, rare nucleated cell, no blast
Cytochemistry
: numerous cell debris and very rare blood cell
have been observed, no hematologic
malignancy cell
:Other cause of bone marrow destruction
should be ruled out
Flow cytometry: blast gate 2.63% of total event
No evidence of hematologic malignancy
1st admission
HISTOPATHOLOGY REPORT
1st admission
Splenic hemagiomatosis
(1st admission)
Splenic hemagiomatosis
(1st admission)
Bone marrow biopsy:
Bone marrow necrosis
No malignancy cell
Bone biopsy at Lt
humerous:
Bone marrow necrosis
No malignancy cell
BONE MARROW NECROSIS (BMN)
Necrosis of myeloid tissue and medullary
stroma in the large areas of hematopoietic bone
marrow
On BM biopsy: disruption of the normal bone
marrow architecture with a considerable loss of
fat space
Aplastic anemia: only loss of myeloid tissue
and no destruction of reticular structure
Aseptic necrosis: no destruction of the spicular
architecture
Hypoxemia after failure of microcirculation:
Inflammatory damage or mechanical obstruction
: DIC, sickle cell disease or tumor cell plug
Immune process
Toxicity and the release of toxins, cytokines,
or vasoactive substances from damaged cells
: TNF
Major complication: pancytopenia, embolic processes
Repopulation of the bone marrow cavity
can occur after BMN resolved
IDENTIFIED UNDERLYING MALIGNANCY
90%
Extensive search for neoplastic
disease is justified whenever BMN
is diagnosed
1st described by Wade and Stevenson, 1942
: Sickle cell disease, died of cerebral infarction
Nies et al. 1965: define BMN in acute leukemia
34/ 316 (10.75%) postmortem
Kiraly and Wheby.1976: 13/664 (2%) in BM
specimens during 12 –year period
Norgard, 1979. retrospectively reviewed 120/368
(32.5%), only 4 were diagnosed at initial
GRADING
Small necrotic lesions: <25% of the dimention of
the biopsy (39%)
Intermediate BMN
< 50% (24%)
Large BMN
>75% (12%)
Extensive: throughout the dimension of the
specimen
Pennaforte et al. 1986: extensive 4/1149 (0.3%)
Maisel etal. 1988: severe BMN > 50% of
dimension (3%)
BMN IN CHILDREN
Macfarlane and Tauro: 4/379 (1%) in ALL
Pui et al: 7/1419 (0.5%) in cancer patients
BONE MARROW NECROSIS (BMN)
ANN M. JANSSENS ET AL. CANCER 2000
Clinicopathologic entity, rare condition
Review 240 cases, 1980-1999
Inclusion
1. BMN diagnosed during life
2. necrosis > 50% of the diameter of
biopsy specimen
UNDERLYING DISEASE ASSOCIATION
Malignancy 91%
Hematologic malignancies 60%
Acute leukemia 41%, lymphoma 15%
ALL 18%, AML 13%
Children 18/25 cases were ALL
BMN developed before diagnosis: ALL 26/37
(AML 16/24)
After induction chemotherapy 1/37
At recurrence 10/37
UNDERLYING DISEASE ASSOCIATION
Solid tumors 30%
Not found primary origin, even after extensive
search 12/43
Non malignancy only 9%: sickle cell crisis,
infection, drug, HUS, antiphospholipid
syndrome, DIC, hyperparathyroidism, anorexia
nervosa, idiopathic etc.
16/22 documented infection: underlying
malignancy were found later (early - 1 yr)
Infection
E.coli
Streptococcus
Staphylococcus
Citrobacter freundii
Salmonella
Mucormycosis
Q fever
TB
Parvovirus
HIV
Drug
Sulphasalazine
Sulphathiazol
Sulphanamide
Interferon-alpha
G-CSF
ATRA
Hydroxyurea
Fludarabine
PRESENTATION
Bone pain
75%
Fever
68.5%
Anemia
91%
Thrombocytopenia
78%
Leukoerythroblastic picture
51%
Elevated LDH, alkaline phosphatase 50%
Leukoerythroblastic picture
primitive red cells (nucleated rbc or erythroblasts)
primitive white blood cells (myelocytes)
Cytology
Bone marrow aspiration can be unsuccessful
Multiple aspirates from different sites
(sternal, posterior iliac crest, etc.)
Serosanguineous, watery dark red or clear fluid
Histology
Combination of gelatinous transformation and
necrosis of the myeloid tissue
Background of gelatinous transformation
surrounds cellular debris with indistinct cellular
margins, pyknotic nuclei, and abnormal
eosinophilic staining cytoplasm
The hallmark of bone necrosis: loss of
osteocytes, osteoblasts, and osteoclasts
background of amorphous extracellular eosinophilic
material that surrounds cells that disintegrate.
shows cells that lose their normal staining characteristics.
irregular or indistinct margins; the cytoplasm can shrink or
vacuolate, and the nucleus shows pyknosis, karyorrhexis, and
karyolysis
Bone Marrow Scanning
Technetium 99m sulfur colloid and indium
chloride localize selectively to the
reticuloendothelial elements of the marrow
Dx BMN, residual BM activity, guided biopsy,
recovery
MRI: changes in bone marrow signal intensities
Life-threatening complication:
embolization of fat and necrotic bone marrow
to pulmonary arteries
PROGNOSIS
Median survival of the hematologic
malignancies :1 - 4 months, 69% died
Childhood ALL: 13/18 alive
Survival: 4 months- 6 years
Solid tumor and BMN: widespread
metastasis, short survival
PROGRESSION OF THE PATIENT
High grade fever
Petechiae hemorrhage at face, periorbital
Increased hepatomegaly
Blood component therapy, antibiotic, pain
management
Consult for liver biopsy
Repeat BMA and biopsy
Plan MRI liver and bone
Steroid
Hepatomegaly
CBC Hb Hct cWBC NRC N L M E other
D1 5.1 15.9 8.8 130 50 35 10 5
D3 6.7 21 3.3 200 32 41 13 4band2, meta2,myelo1, atyp L5
D10 6.1 19.5 11.7 80 36 44 16 4
D15 6.9 21.3 4.1 21 60 30 5 2band2 atypl1
D16 5.7 17.4 3.9 19 41 55 2 atyp3
D17 8.2 24.3 4.9 44 42 52 3 band 2, atyp1
D24 7.4 21.6 10.8 31 42 38 9 band6, atyp 5
D25 9 26.8 7.8 48 38 40 10 band2, meta3, myelo1, atyp 4, blast2
D30 7.4 22 3.2 50 49 32 9 blast10
D31 6.8 20.2 9.2 52 41 47 10 atyp2
D35 5.6 17 15.1 42 38 10
blast8,atyp2
Plt
172
144
27
7
74
21
40
30
49
34
13
Developed massive GI bleeding
treatment: LPB, Platelet, FFP, antibiotic
Cardiac arrest: CPR x 30 min
ABG
pH PCO2 PO2 HCO3 ABE O2 sat
7.07 19.2 444 5.7 -22 100
PT INR PTT D-dimer
31.2 2.67 34.4 0.6 mg/L
Bone marrow aspiration at
sternum
BM biopsy from
1. right ASIS:
Abnormal blast cells infiltrate with focal
necrosis and crush artifact
2. A small amount of marrow tissue from Lt
ASIS: abnormal blast cells
3. Sternum: numerous blast cell infiltrate
: precursor T lymphoblastic leukemia/
lymphoblastic lymphoma
CD3+, CD20-, CD79a-, CD34-, MPO-, TdT+
Liver biopsy
: precursor T lymphoblastic leukemia/
lymphoblastic lymphoma
CD3+, CD20-, CD79a-, CD34-, MPO-, TdT+
THANK YOU
Extensive search for neoplastic disease
Multiple aspirates from different sites
: biopsy site in which viable hematopoietic
bone marrow