Student details , SANTU SAHA ,
IQCMC , Durgapur , India
Class - General Medicine ward ( 4th semester )
Age : 19 years
Sex : Male
Occupation : College student
State : West Bengal
Year : 2017
#Chief complains
1. Recurrent fever
2. Pain around left iliac crest
#History of present illness
Since 3 months, the patient is suffering from recurrent fever. When he started taking medicine the fever subsided. But as he stopped taking the medicines , he again developed fever. There is no particular timing of his fever. He has developed hepatomegaly and along with sign of pallor. It seems that he also has pleural effusion.
And , due to arthralgia , he was unable to extend at the level of his Right elbow.
#History of past illness
Regarding the Pain
1. Onset : 20 - 25 days ago, for 4 - 5 days ,then followed by fever
2. Position : Pain around left iliac crest
3. Quality : continous pain
4. Relieving or Aggravating factor : no such factor
5. Severity : intolerable
6. Timing : no specific timing
He never had any major or minor surgery operated on him.
Also , 2.5 months ago , he was diagnosed with Typhoid fever.
Then after medication, he was apparently well for the next 15 days. He suddenly developed malaise followed by a series of recurrent fever.
Subcutaneous spot of bleeding could be seen in left arm.
A supernumerary nipple can also be seen on the left half of abdomen along the milk line (Line of Schultz).
#Family history
Grandmother - breast cancer
Aunt - died undiagnosed
Father - died at the age of 28 years, due to rectal cancer
#Drug history
No allergy for drugs.
#Personal history
Appetite : normal
Sleep : normal
Built : weak and slim
Rate of respiration : High (> 30 breaths per minute)
Pulse rate : High (95 pulses per minute)
Heart rate : High ( tachycardia)
Tremors, Cyanosis, Clubbing : absent
#Findings
USG report of whole abdomen shows that liver is enlarged in size, gallbladder is contracted, spleen is normal in size with echotexture.
Mild free fluid is also seen in the peritoneal cavity.
Thus, hepatomegaly and mild Ascites has been inferred.
#Peripheral Smear Findings
RBC : RBCs predominantly Normocytic Normochromic. Moderate anisopoikiliocytosis seen. Moderate polychromasia seen , nRBCs - 17/100
WBC : Total count within normal limits . Blasts - 40 % , Neutrophil - 26 % , Lymphocytes - 28 % , Eosinophils - 1% ,Monocytes - 5%
Platelet : Reduced on smear
Finally , when immunophenotyping was performed it has been observed that it's a case of precursor B cell acute lymphoblastic leukaemia ( Pre B-ALL) with a aberrant CD33 expression.
#And now , here are few University questions, related to the topic , that are often asked :
Pathology
1. Leukemia definltion
2. FAB classifications
3. Peripheral blood picture and laboratory diagnosis of AML , CML , ALL , CLL
4. Aleukemic leukemia- short note
5. Leukemoid reaction Leukemia are not very easy to differentiate-comment
6. Philadelphia chromosome
7. Diagnostic criteria of blastic phases of chronic myeloid Leukemia
General Medicine
1. Causes of generalized lymphadenopathy
2. Clinical staging of Hodgkin lymphoma
3. Peripheral blood picture in patient of CML in blast crisis
4. Difference between NHL and HL
5. CML - First line therapy
#Treatment of the patient
At present patient is in remission ( disease free) after first induction therapy. But MRD positive means minimal residual disease present. He is taking second phase of chemotherapy in day care.
#Method in use : The Berlin-Frankfurt-Munster (BFM) 2002 ALL Protocols
#Details of the treatment method
Acute Lymphoblastic Leukemia in Children
A Brief Review of the Internationally Available Protocols
The following medicines are available in the first edition of the Essential Medicines List for children.
Cytotoxic medicines
Complementary List
A) allopurinol Tablet: 100 mg to 300 mg.
B) asparaginase Powder for injection: 10 000 IU in vial.
C) bleomycin Powder for injection: 15 mg (as sulfate) in vial.
D) calcium folinate Injection: 3 mg/ml in 10‐ml ampoule.
Tablet: 15 mg.
E) chlorambucil Tablet: 2 mg.
F)cisplatin Powder for injection: 10 mg; 50 mg in vial.
G) cyclophosphamide Powder for injection: 500 mg in vial.
Tablet: 25 mg.
H) cytarabine Powder for injection: 100 mg in vial.
I) dacarbazine Powder for injection: 100 mg in vial.
J) dactinomycin Powder for injection: 500 micrograms in vial.
K) daunorubicin Powder for injection: 50 mg (as hydrochloride).
L) doxorubicin Powder for injection: 10 mg; 50 mg (hydrochloride)
in vial.
M) etoposide Capsule: 100 mg.
Injection: 20 mg/ml in 5‐ml ampoule.
N) fluorouracil Injection: 50 mg/ml in 5‐ml ampoule.
O) mercaptopurine Tablet: 50 mg.
P) methotrexate Powder for injection: 50 mg (as sodium salt) in vial.
Tablet: 2.5 mg (as sodium salt).
Q) procarbazine Capsule: 50 mg (as hydrochloride).
R) vinblastine Powder for injection: 10 mg (sulfate) in vial.
S) vincristine Powder for injection: 1 mg; 5 mg (sulfate) in vial.
Under the BFM 2002 ALL Protocols
Outline of Induction has been given below in the diagram
# Prednisone prephase therapy: Patients receive oral prednisone on days 1‐7
and one dose of methotrexate (MTX) intrathecally (IT) on day 1.
# Induction/consolidation therapy, protocol I: Patients are randomized to 1 of 2
treatment arms.
#Bibliography
1) https://clinicaltrials.gov/ct2/show/NCT00114348
2) http://ascopubs.org/doi/full/10.1200/jco.2013.48.6522
3) WHO - Cytotoxic medicines ( Review )
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