CASE PRESENTATION

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CASE PRESENTATION
BY DR ROHAN
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CHIEF COMPLAINTS
MALE PATIENT BY NAME XXXXXX YYYYYY OF AGE 51
YEARS

• FEVER SINCE 1 MONTH
• LOSS OF APPETITE SINCE 1 MONTH
• LOSS OF WEIGHT SINCE 1 MONTH
• WEAKNESS AND FATIGUE SINCE 1 MONTH

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GENERAL PHYSICAL EXAMINATION

• PALLOR
• LYMPHADENOPATHYINGUINALAXILLARY
• SPLEENOMEGALY 12 CM

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INVESTIGATIONS
CBC
30/06/07 1/07/07 06/07/07 09/07/07 13/07/07 17/07/07
HB 6gm 5.7gm 5.9gm 6.4gm 7gm 6.3gm
TLC 20k/ul 17.4k/ul 18.2k/ul 19.6k/ul 19.3k/ul 19.7k/ul
PL 161000 136000 206000 199000 196000 189000
PCV 17.4 17 18.8 20 22 21
MCV 68.5fl 71fl 73fl 73fl 73fl 76.9fl
LYM N 88 11 76 17 74 19 81 18 80 14 80 13
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PERIPHERAL SMEAR

• MICROCYTIC HYPOCHROMIC
• LYMPHOCYTOSIS PRESENT
• NO ABNORMAL LYMPHOCYTES OR LYMPHOBLAST
• ROULEAUX FORMATION PRESENT

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LIVER FUNCTION TEST
TEST STATUS RESULT REFERENCE RANGE
TOTAL BILLIRUBIN RC 0.02 mg/dl 0 -1
DIRECT BILLIRUBIN RC 0.06 mg/dl 0-.3
S.G.P.T RC 24 u/l 30-65
S.G.O.T RC 20 u/l 15-37
ALK. PHOSPTASE RC 84.00u/l 50-136
TOTAL PROTEINS RC 13.70 gm/dl 6.4-8.2
S. ALBUMIN RC 2.80 gm/dl 3.4-5
S.GLOBULIN RC 10.90 gm/dl 1.4-3
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RENAL FUNCTION TEST
TEST STATUS RESULT REFERENCE
S.CREATININE RC 1.40 mg/dl 0.6-1.3
BUN RC 9 mg/dl 7-18
BLOOD UREA RPR 19.26 mg/dl 15-45
S.URIC ACID RC 8.80 mg/dl 2.6-7.2
BUN/CR RATIO RPR 6.43 10-20
TOTAL PROTEINS RC 13.70 gm/dl 6.4-8.2
S.ALBUMIN RC 2.80 gm/dl 3.4-5
S.GLOBULIN RC 10.90 gm/dl 1.4-3
A/G RATIO RC 0.26 1-3
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OTHER SPECIFIC INVESTIGATIONS

• Serum LDH was normal 281 u/lreference -225-450
  u/l
• ESR was 100mm
• Urine routine showed albumin 1,rest normal
• Retic count was normal
• Malarial parasite not seen
• Serum iron was low-14.47ug/dl
• TIBC was 211u/dl
• FBS-PLBS normal
• CT abdomen showed massive speenomegaly
• Serum calcium was 9.60mg/dl
• Serum electrolytes were normal

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SERUM PROTEIN ELECTROPHORESIS
TEST RESULT
TOTAL PROTEIN 11.5GM/100MLHIGH
ALBUMIN 3.7GM/100ML
GLOBULIN 7.8GM/100MLHIGH
ALPHA1 GLOBULIN 0.26GM/100ML
ALPHA2 GLOBULIN 0.66GM/100ML
BETA GLOBULIN 0.48GM/100ML
GAMMA GLOBULIN 6.41GM/100MLHIGH
ALBUMIN-GLOBULIN 0.47
CRYOGLOBULIN ABSENT
PYROGLOBULIN ABSENT
MACROGLOBULIN ABSENT
M BAND URINE PROTEIN ELECTROPHORESIS PRESENT BENCE JONES PROTEINS PRESENT
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BONE MARROW ASPIRATE IMPRINT OF BIOPSY
SITE PSIS
ASPIRATE EASY
CELLULARITY GOOD
ME RATIO 31
MYELOID SERIES NORMAL
ERYTHROID SERIES NORMOBLASTIC
MEGAKARYOCYTES ADEQUATE
PLASMA CELLS 15
LYMPHOCYTES 4520 ARE PLASMACYTOID
OTHERS --
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IMMUNOPHENOTYPING
MARKERS RESULTS
Lymphoid markers B cells
CD10 NEGATIVE
CD11C NEGATIVE
CD19 79
CD20 80
CD22 55
CD23 70
CD25 NEGATIVE
CD38 66
CD103 NEGATIVE
KAPPA 92
LAMBDA NEGATIVE
T CELL MARKERS NEGATIVE
SERUM IMMUNOFIXATION STUDY SHOWED IGM K
MONOCLONAL GAMMOPATHY
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FINAL DIAGNOSIS

• WALDENSTROMS MACROGLOBULINEMIA

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TREATMENT

• PACKED CELLS -4 BAGS
• INJ GRANISET 3 MG INJ PANTODAC 40MG I.V IN 10
  ML NS OVER 15 MINS
• INJ ENDOXAN 1GM I.V IN 250ML NS OVER 1 HR X 1 DAY
• INJ VINCRISTINE 2MG I.V SLOWLY WITHOUT
  EXTRAVASATION X 1 DAY
• TAB OMNACORTIL 20 MG 1-2-2AFTER MEALS X 5 DAYS
• TAB PAN 40 1-0-1 X 2 WEEKS
• TAB ZYLORIC 100MG 1-1-1 X 2 WEEKS
• TAB FOLVITE 5MG 1 OD X 3 WEEKS
• CAP BECOSULE 1 OD X 3 WEEKS
• TAB NEURODAY 1 OD X 3 WEEKS
• CAP VITCOFOL 0-0-1 X 3 WEEKS
• REPEAT SAME TREATMENT EVERY 3 WEEKS X 6- 8 CYCLES
  IF EFFECTIVE AND TOLERABLE

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RESPONSE TO TREATMENT
AFTER 1ST CYCLE AFTER 2ND CYCLE
SPLEEN SIZE 10 CM 8 CM
HB 7.2 GM 8.8 GM
TLC 16.2 K/UL 13.1 K/UL
PL 129 K/UL 138 K/UL
LYM 77 71
N 18 25
SR CREAT 0.70 MG/DL 0.69 MG/DL
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RESPONSE AFTER 3RD CYCLE

• SPLEEN SIZE- 6CM
• HB - 7.9GM
• TLC -9.9 K/UL
• PL -148 K/UL
• LYM -52
• N 42
• SR CREAT- O.6 MG/dl

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THANK YOU