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Case Study: Acute Myeloid Leukemia in a 42-Year-Old Male

A case study of a 42-year-old male presenting with multiple symptoms including neck swellings, fever, and weight loss, diagnosed with Acute Myeloid Leukemia (AML) M4 with malignant pleural effusion. The text details etiology, clinical features, blood parameters, classifications, prognosis, and management strategies in AML.

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Case Study: Acute Myeloid Leukemia in a 42-Year-Old Male

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  1. A CASE OF ACUTE MYELOID LEUKEMIA PROF S SHIVAKUMAR P SENTHIL KUMAR MD PG

  2. Rajendran • 42 yrs/ M • c/o • Multiple swellings in the neck and submandibular region • Fever • Breathlessness 3months • Pain abdomen • Loss of appetite/ Loss of wt. • No cough with sputum • No dysuria, rashes, jaundice • Bowel and bladder - N

  3. Past H/o • No DM/ HTN/ IHD/ PT/ BA/ STROKE • Personal H/o • Smoker/ alcoholic • Agricultural worker • Family H/o • Nil • Treatment H/o • Pt on ATT for PL effusion past 3 months

  4. O/E • Conscious • Oriented • Febrile • Pallor + • Clubbing+ • Subconjunctival hemorrhage • Submandibular/ cervical / supraclavicular LN + • No icterus/ cyanosis/ PE/ JVP.

  5. RS • BS Lt mamary/ infra axillary/ infrascapular areas • Stony dullness • Chest wall movements Lt side • CVS • S1 S2 + • No murmur • ABD • No organomegaly • No FF

  6. LAB • Hemogram • Hb - 5.6 g/dl • TLC - 30,100/cu mm • DC - blast 60% P24 L 04 Myelocyte 12 • Platlets - 20.000/ cu mm • RBC - 1.6 million/ cu mm • PCV - 15 %

  7. PERIPHERAL SMEAR • RBC - Normochromic Normocytes and few hypochromic microcytes. - No hemoparasites seen • WBC - Count increased with BLASTS showing occasional Auer Rods. • PLATLETS- Diminished

  8. BONE MARROW • Hypercellular Marrow replaced by Leukemic cells with BLAST showing MYELOID MONOCYTIC differentiation up to 70 % • ERYTHROPOIESIS • MEGAKARYOPOIESIS • CYTOCHEMISTRY • MPO - Inconclusive • PAS - Neg

  9. RFT • Urea - 32 mg/dl • Creatinine - 0.8 mg/dl • Bl sugar - 105 mg/dl • LFT • TB - 0.7 mg/dl • DB - 0.3 mg/ dl • SGOT - 24 Iu/L • SGPT - 22 Iu/L • SAP - 1O5 Iu/L

  10. CXR - Lt pleural effusion • ECG - WNL • USG ABD - Lt pleural effusion - LIVER/ SPLEEN normal • SPUTUM • AFB - Neg • Grams stain - Neg • Malig cells - Neg

  11. Pleural Fluid • Protein - 4.6 g/dl • Sugar - 84 mg/dl • WBC - 2600/ cu mm ( P 11 L 39 ) • RBC - 30,000/cu mm • Smear - +ve for MALIGNANT CELLS • Grams stain - No organisms • AFB - Neg

  12. Problems • Fever • Lymphadenopathy • Pleural effusion • Subconjunctival hemorrhage • Loss of wt

  13. DIAGNOSIS ACUTE MYELOID LEUKEMIA – M4 WITH MALIGNANT PLEURAL EFFUSION

  14. ACUTE MYELOID LEUKEMIA

  15. ETIIOLOGY • HEREDITY - Downs , Klinefelters, patau, Chromosomal breakage syndromes • RADIATION • CHEMICAL - Benzene, smoking, paint, petroleum, pesticides. • DRUGS - Alkylating agents, Topo isomerase II inhibitors, Chloramphenicol and phenyl butazone.

  16. CLINICAL FEATURES • Age of onset - Adult onset and incidence increases with age • M/F - 4.4 : 3 • Fatigue • LOW/ LOA • Fever with or without infection • Bleeding symtoms • Bone pain • Lymphadenapathy • Hepatosplenomegaly • GI, PUL, Intra cranial, Retinal hhage (APL – M3) • Chloroma ( M1 M2) • Gum hypertrophy (M4 M5 )

  17. BLOOD PARAMETERS Anemia with dec Retic count WBC – mean 15,000 <5000 in 25 – 40% > 100,000 in 20% No malig cells in 5% Dysfunction + Platlets - < 100,000 in 75% < 25000 in 25% Dysfunction +

  18. CLASSIFICATIONS • FAB • Based on Morphological charecteristics • BLAST cells > 30 % • WHO • BLAST cells > 20 % • Based on Morphology, Molecular and CF.

  19. FAB • M0 - Minimal diff • M1 - Myeloblastic without maturation • M2 - Myeloblastic with maturation • M3 - Promyelocytic • M4 - Myelomonocytic • M4E0 - Marrow eosinophilia • M5 - Monocytic • M6 - Erythroleukemia • M7 - Megakaryoblastic

  20. WHO • AML I – GENETIC abnormalities • t ( 8/21), inv (16), t (16/16) • MLL abnormalities • APL t ( 15/ 17) • AML II- Following myelodysplasia/ myeloproliferative disorders • AML III- Following DRUG induced myelodysplasia • AML IV – M0 to M7 of FAB , panmyelosis, basophilic and myeloid sarcoma

  21. GOOD Young age Chromosomal defects (t8/21, inv 16, t15/17) Rapid induction of CR Long duration of CR POOR Advanced age ( > 60) Chrom defects ( inv 3, -7 ) Asso med illness Prolonged cytopenias Prev myelodysplasia Drug induced AML Delayed and short duration of CR PROGNOSIS

  22. MANAGEMENT • REMISSION INDUCTION • POST REMISSION MANAGEMENT

  23. REMISSION INDUCTION (7&3 REGIME) • CYTARABINE • 100 – 200 mg / sq m/ day IV infusion 7 days • ANTHRACYCLINE • Daunorubicin – 45- 60mg/sq m/day IV 3 days • Idarubicin - 12 mg/sq m/ day IV • With or without ETOPOSIDE

  24. COMPLETE REMISSION • Blood • WBC >1500 • Platlet > 1 Lac • RBC count not considered • No BLAST cells • BM • Trilineage cellularity > 20% • Blast cell < 5% • NO Auer rods • RT PCR/ FISH to r/o residual leukemic cells

  25. If 7 & 3 Regime • 50% - CR • start 5 & 2 Regime • 25% - CR • 25% - NO CR • NO CR • 50% - Drug Resistance • 50% - Fatal complications of Drugs

  26. HIGH DOSE CYTARABINE 3-4 cycles 3 g/sq m / day bd on 1,3 & 5 th day STEM CELL Tx Autologous allogenic LESS INTENSIVE CHEMOTHERAPY STEM CELL Tx Non myeloablative Allogenic POST REMISSION MANAGEMENT AGE < 65 yrs AGE > 65 YRS

  27. TREATMENT OF APL ( M3) • TRETINOIN( Maturation of blast cells,No DIC) • 45 mg/ sqm/day Untill remission • ANTHRACYCLINES • Maintanance therapy • Tretnoin or chemotherapy

  28. RELAPSE STEM CELL TX

  29. thank u

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