Medicine Grand Rounds Clinical Vignette

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Medicine Grand RoundsClinical Vignette

• October 31st, 2007
• Joshua Remick, M.D.

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Chief Complaint

• 25 year old African American man who presented
  with 40 pound weight loss over 2 months and 2
  weeks of weakness, nausea, vomiting and night
  sweats.

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History of Present Illness

• The patient had no known medical history
• He was in his usual state of excellent health
  until 2 months prior when he began to notice
  weight loss despite a normal appetite.
• Over the past 2 weeks, his symptoms progressed to
  include nausea, vomiting and night sweats.
• He denied fevers, chills, cough or SOB.
• He also denied any bruising or epistaxis, melena,
  or hematuria.

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Further History

• Medications none
• Allergies no known drug allergies
• Family History no known cancer or heart disease
• Social History denies tobacco, EtOH or IV drug
  use

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Physical Exam

• General well appearing, no apparent distress
• VS T 99.6 HR 100 BP 121/66 R 15 O2 96 RA
• HEENT anicteric sclera, and normal, moist mucous
  membranes.
• Lymph shotty supraclavicular, axillary and
  inguinal LAD
• Abdomen soft, mild midepigastric tenderness to
  palpation, and massive splenomegaly
• The remainder of the physical exam was
  unremarkable

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Laboratory Findings

• WBC 63,000 52 Neut., 5.5 Lymph
• Hgb 7.4 g/dL, MCV 93.8, RDW 17.7
• Platelets 46,000
• Smear 30-40 blasts of various sizes, few
  promyelocytes and myelocytes, decreased
  platelets, no Auer rods observed
• BUN 32 Cr 2.4
• LFT WNL
• LDH 2341 Uric Acid 12.2
• PT 14 INR 1.14 PTT 27.3
• Fibrinogen 426 D-dimer 11

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Further Studies

• ECG normal sinus, normal axis, normal intervals,
  no ST-T changes
• CXR congestion of the pulmonary vasculature with
  small b/l pleural effusions normal appearing
  heart size and contours

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Working Diagnosis

• Acute leukemia, suspicious for chronic
  myelogenous leukemia

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Hospital Course

• The patient was treated with IV fluids and
  Allopurinol and his renal failure resolved. He
  also underwent a bone marrow biopsy on HD1 which
  revealed
• Small population (5) of myeloid blasts on flow
• Aspirate smear revealed increased myeloid
  precursors at all stages of maturation
• Megakaryocytes in decreased numbers with normal
  morphology
• FISH analysis positive for 821 translocation

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Updated Diagnosis

• Acute Myeloid Leukemia, FAB class M2

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Hospital Course

• On hospital day 2, the patient had MUGA scan
  revealing a normal appearing heart with an EF of
  58.
• He also had a CT scan of his Neck/Chest/Abdomen
  and Pelvis which revealed extensive
  lymphadenopathy involving the left
  supraclavicular, submental, submandibular,
  mediastinal, jugulodigastric, retroperitoneal,
  and pelvic groups.
• The CT also identified bilateral paravertebral
  soft tissue masses and diffuse lung nodules, as
  well as pleural and pericardial thickening.

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Hospital Course

• On HD3, the patient began induction chemotherapy
  with Cytarabine/Idarubicin
• On HD10, the patient became neutropenic and the
  appropriate neutropenic precautions were
  undertaken
• On HD13, the patient developed neutropenic
  fever. The source was never clearly determined
  and the patient recovered after a course of
  vancomycin, amikacin, and pipercillin/tazobactam.

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Final Diagnosis

• Acute Myelogenous Leukemia, FAB class M2
  complicated by neutropenic fever.