Transcript Morning Report

Morning Report
Jieli Li
11/14/05
Chief Complaint
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f/c, n/v, abdominal pain
HPI
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34 y/o AAM with hx of PSA presents with f/c, n/v
and abdominal pain x 5 days.
Pt developed nausea and lack of appetite about 1 wk
ago, followed by fevers and epigastric/RUQ pain.
His mother who is a nurse told him to try Bye-lori
2(a herbal medication for H. pylori). Pt had no relief
of symptoms
The morning of presentation pt had emesis x 1 in
shower and a sharp pain in his right groin region
where he had an old hernia years ago. He decided to
come into clinic to seek medical help
HPI cont.
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Pt also noticed a patchy rash on his abdomen and
around both eyes and right upper back x 5 days.
+ “tarry brown” stools for the last few days
+ dark/concentrated appearing urine despite drinking
plenty of water
Denies any cough, dysuria, grosshematuria,
diarrhea/constipation, BRBPR.
PMH
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PSA
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etoh - quit in 1998,
ecstasy, LSD, cocaine - quit in 2000
heroin - once (IVDA)
MJ and smoking – quit 2 months ago
History cont.
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All:
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Meds:
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Penicillin – hives, anaphylaxis
Bye-lori 2 – homeopathic med for H. pylori
SH:
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Pt works as an actor
His mother has been a nurse for 40 yrs
HIV, Hep C and other STD’s tested in 1994, neg per pt
No sexual activity since 02/2004 per pt
Denied homosexuality
Physical Exam
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VS – T: 102.4, HR: 126, BP: 142/78, RR: 20
Ht: 177.8 cm, Wt: 65.2 kg, BMI: 20.6
Gen – thin but well-developed AAM in mild to moderate distress, + chills, + slight
diaphoresis. AAO x 4
Skin – slightly diaphoretic, + periorbital erythematous, non-blanching fine rash,
also similar patchy rash on abdominal skin (RUQ and epigastric) and right upper
back
HEENT – Mild jaundice, NC/AT, PERRLA, EOMI, no oral lesions
Neck – supple w/o LAD, no thyromegaly
Heart – tachycardic, regular rhythm, s1s2, no m/r/g
Lungs – cta bilaterally, no wheezes/crackles
Abd – scaphoid, hypoactive BS, + mild to moderate tenderness RUQ and
epigastric region. No rebound, no guarding. No CVA tenderness. +
hepatosplenomegaly. +small reducible hernia right groin. Non-tender.
Ext – no c/c/e
Neuro – CN II-XII grossly normal, non-focal
Laboratory
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9.82
17.2
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30.8
27.7
MCV 85.2, 32% neutrophils
20% lymphs, 43% monos, 4%
basophils
130
100
22
Ca , Mg , P
Lactate 8.3
1.3
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17
99
4.23
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Stool ob positive
PT 18.4, PTT 28.6, INR 1.6
Haptoglobin 5.83, direct and
indirect Coombs neg
Heterophile neg
Alk phos 135, ALT 104, AST
192, total bili 3.7, direct bili 1.4
Amylase 52
U. tox - + marijuana
UA – small bilirubin, small
occult blood, 3 RBC, trace
protein, urine urobilinogen > 8.0
Additional Labs
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HIV NR
RPR NR
Malaria smear neg
Cryptococcus neg
CMV neg
Coccidioides neg
CSF cx’s (varicella, mycology, viral, bacterial, AFB) neg
Stool cx’s neg
VZV neg
Rocky Mountain Spotted Fever neg
Leptospira neg
Murine typhus neg
Ehrlichiosis neg
West nile virus neg
Ultrasound of Abdomen (10/03/05)
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Liver and spleen are enlarged. They are
homogeneous in echo texture without
evidence of focal mass. No evidence of
cholelithiasis or biliary dilatation. No definite
pancreatic masses.
Kidneys are normal in size and in echotexture.
Main portal vein is patent. No evidence of
ascites.
HIDA scan
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No definite visualization of the gallbladder
during approx 2 hours and 20 minutes of
imaging after radiopharmaceutical injection.
This is consistent with acute cholecystitis
There is no evidence of intrahepatic or
common duct obstruction
CT abdomen/Pelvis (10/12/05)
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Pericholecystic fluid distended gall bladder
consistent with acute cholecystitis
Hepatosplenomegaly. Mild fatty change in
the liver
Small amount of fluid within the pelvis
Again identified is distended urinary bladder
Bone Marrow Biopsy (10/12/05)
Hospital Course
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Patient was initially admitted to MICU. Differential was
broad given the constellation of symptoms. Multiple
subspecialty services were consulted including ID, GI,
Heme/onc, General surgery (for possible ischemic bowel and
later for acalculous cholecystitis). Patient required multiple
units of blood products to keep Hgb > 8 and plts > 50.
Pt had episodic melena and one episode of hematemesis as an
inpatient, GI workup included a normal EGD, however pt
refused colonoscopy. Pt was treated with 14 days of
levofloxacin and flagyl for acute cholecystitis on HIDA and
CT abdomen. Gen surgery plans to do cholecystectomy as
outpatient.
Hospital Course
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Pt developed throbbing headache lasting for 2-3 hrs. Spinal
tap was done, which revealed possible aseptic meningitis.
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Patient underwent induction chemo with cytarabine and
idarubacin. Finished first cycle on 10/21/05, developed
neutropenia with ANC down to 0. Pt was placed on modified
neutropenic precautions (e.g, roams floor). However pt was
non-compliant and refused to stay in room. He initially did
well, but then spiked fever on 10/30. Was placed on multiple
abx. Counts eventually rebounded and pt will be discharged
home this week.
Acute Myeloid Leukemia
Introduction
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A clonal disorder of the early myeloid cells. During normal
hematopoiesis, myeloid blast cells differentiate into
granulocytes, monocytes, erythrocytes, or megakaryocytes.
Malignant cells replace bone marrow, may infiltrate spleen,
liver, lymph nodes and circulate in bloodstream
Usually less nodal involvement than ALL
80% of adult leukemias vs. 20% for ALL; 20% of childhood
leukemias vs. 80% for ALL
Can develop after transformation from myeloproliferative
disorders, myelodysplastic disorders, and PNH
Overall 5-year survival is < 20%
Risk Factors
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Down syndrome
Bloom syndrome
Fanconi’s anemia
Neurofibromatosis
Benzene exposure
Radiation
Alkylating agents
Type II topoisomerase inhibitors
Signs and Symptoms
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Due to replacement of normal bone marrow cells by
blasts
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fatigue - due to anemia
fever
opportunistic infections - due to neutropenia
mucosal and cutaneous bleeding - due to
thrombocytopenia
tissue infiltration (mainly with M4/M5)
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sternal tenderness - due to bone marrow expansion
gingival hyperplasia
neurological symptoms - due to CNS infiltration
Diagnosis
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Morphology
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Cytochemical tests
Immunophenotyping
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Myeloblasts have delicate nuclear chromatin, 2-4 prominent nucleoli, more
voluminous cytoplasm than lymphoblasts in ALL, often with fine granules
and Auer rods (abnormal crystallized granules, particularly in M3)
Monoblasts (M4, M5) have folded or lobulated nuclei, no Auer rods
Peripheral smear - 50% have WBC > 10,000, 20% > 100,000 due to
circulating blasts and other immature myeloid cells
Bone marrow - hypercellular, 20% or more blasts (by definition)
CD99 – positive in 43% of AML
CD10 - usually negative vs. positive in ALL
Chromosomal analysis
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90% have chromosomal abnormalities
De novo cases often have balanced translocations
Auer rods
FAB Classification
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M1 is AML without maturation
M2 is partially differentiated AML
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M3 is acute promyelocytic leukemia (APL)
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resembles M2 except that approximately 25% of the cells are myeloblasts and
promyelocytes and 25% are monoblasts and promonocytes/monocytes.
M5 is acute monocytic leukemia (AMoL)
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> 30% promyelocytes
M4 is acute myelomonocytic leukemia (AMML)
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> 50% of the cells being myeloblasts and promyelocytes and with myelocytes
and metamyelocytes present
M5a without maturation
M5b with partial maturation.
MB is erythroleukemia (EL)
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> 50% or more nucleated bone marrow cells are erythroblasts and many
having bizarre features.
Prognosticators
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Cytogenetics
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Low risk  t(8;21),t(15;17), or inv(16)
Intermediate risk  normal karyotype or t(19;11)
High risk inv (3), -5/del(5q), -7, or a more complex
karyotype (3 or more aberrations)
Additional unfavorable prognosticators:
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Age> 60
Poor performancestatus
WBC count > 100,000/mm3
Prior disease of the bone marrow (myelodysplasia or
myeloproliferative disorder)
M3 Promyelocytic Variant
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A favorable AML prognosticator
Associated with a translocation between
chromosomes 15 and 17, involving the
promyelocytic leukemia gene and retinoic acid
receptor  gene (PML-RAR)
Treatment:
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All-trans retinoic acid (which will induce differentiation)
Daunorubicin
> 80% remission and > 70% cure rates
Promyelocytic Variant
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Increased risk for developing DIC due to
release of procoagulants from cytoplasmic
granules
Chemotherapy
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Indution therapy
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Consolidation therapy
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Cytarabine + daunorubicin
The same chemo regimen used for remission
induction can be repeated for one or more cycles
as consolidation treatment
Cure rate 10-30%
Other Treatment Options
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Reserved for patients < 60 yrs old, with a
histocompatible sibling and with poor
prognostic cytogenetics
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Autologous stem cell transplantation
Allogeneic bone marrow transplantation – Cure
rate 45-65%