Transcript Journal Club - NYU Langone Medical Center

NYU Medicine Grand Rounds
Clinical Vignette
Maryann Kwa, MD
PGY-2
January 12, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
The patient is a 39-year-old man presenting
with fever, chills, and a non-productive
cough for one week.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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˚.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
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 normal
UNITED 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
Differential Diagnosis
Acute myeloid leukemia, versus chronic myeloid
leukemia with blast crisis, versus lymphoma
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 Course
• Hospital Day 1:
– Bone marrow biopsy was performed.
– Flow cytometry and cytogenetics were sent.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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)].
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Revised Working Diagnosis
• Acute myeloid leukemia (AML) with
translocation between chromosomes 8
and 21
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
• A repeat bone marrow biopsy showed
complete remission after induction
chemotherapy.
• The patient is currently awaiting consolidation
therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Acute myeloid leukemia (AML) with
translocation between chromosomes 8 and
21, responsive to induction chemotherapy,
now in complete remission.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS