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NYU Medicine Grand Rounds Clinical Vignette

NYU Medicine Grand Rounds Clinical Vignette. Maryann Kwa, MD PGY-2 January 12, 2011. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medicine Grand Rounds Clinical Vignette

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  1. NYU Medicine Grand Rounds Clinical Vignette Maryann Kwa, MD PGY-2 January 12, 2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS The patient is a 39-year-old man presenting with fever, chills, and a non-productive cough for one week.

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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˚.

  4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: • Hemoglobin/Hematocrit 9.0/27 • MCV 87 • Platelets 256 • White blood cell count 11.0

  8. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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)

  9. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis Acute myeloid leukemia, versus chronic myeloid leukemia with blast crisis, versus lymphoma

  11. Additional Laboratory Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Lactate dehydrogenase: 502 (110-225 U/L) • Haptoglobin: 435 (30-200 mg/dL) • Reticulocyte %: 1.99 (0.5-1.5)

  12. Additional Laboratory Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  13. CAT Scan Chest UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Bone marrow biopsy was performed. • Flow cytometry and cytogenetics were sent.

  15. 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)].

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Revised Working Diagnosis • Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21

  17. 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.

  18. 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.

  19. 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.

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