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Flashcards in Singh's Case Studies Deck (69)
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1

66 y/o m with fatigue and fever, with hx of Myelodysplastic syndrome 

fever, tachycardia, petechiae, conjunctival pallor

elevated WBC, decreased Hgb, decreased PLT

Peripheral blood 25% blasts with large nuclei and visible nucleoli

Leukocytosis with ANC of 186 (neutropenic)

Dx: Acute Myeloid Leukemia with infection 

2

Treatment for pt with AML and infection?

Bone marrow shows 55% blasts, start on chemotherapy with antibiotics for presumptive infection, transfusion support as needed 

recheck blast count after two weeks 

3

Pt with AML and infection, has recurrent fever after abx treatment. What do you do?

he's severely neutropenic from chemo, do a culture from central line. Make sure to check for fungal infection if gram stain is negative 

treat bacteria/fungus and treat neutropenia with GM-CSF

4

What are the three phases of Chemo treatment?

Induction: initial chemo to induce a remission 

Consolidation: intensify chemo to make sure no cancer cells are left in body 

Maintenance: longer term therapy to maintain remission 

Consider stem cell transplant for some cancers 

5

What is the prognosis for our pt with AML? 

age >60 and pre-existing MDS are concerning and there is a high rate of relapse 

needs close monitoring 

6

Next pt, 38y/o fm with complaints of weakness, bruising, menorrhagia 

 

tachycardia, purpura, conjunctival pallor, 

leukopenia, low Hgb, severe thrombocytopenia

 prolonged PTT/PT

low fibrinogen

D-dimer elevated

Dx: DIC

7

How did we determine our 38y/o f pt has DIC?

Low PLT

Increased PT/PTT

decreased fibrinogen 

fibrin clots forming/degrading leads to increased D-Dimer

 

8

What is underlying condition is causing the 38y/o f pt's DIC?

WBC isn't high, but circulating blasts show Auer rods

She is positive for t(15;17) which confirms Acute Promyelocytic Leukemia

9

How can Acute Promyelocytic Leukemia be treated?

PLT transfusion and factor replacement 

Chemotherapy: 

ATO: arsenic trioxide

ATRA: all trans retinoic acid

10

68yo female with fatigue, weight loss, abdominal fullness 

exam shows splenomegaly 

low Hgb, low reticulocytes, normocytic RBCs

Leukocytosis of 87,400 with mature neutrophils, eosinophils and basophils 

normal PLT

low LAP

 

11

In the 68yo female with splenomegaly and severe leukocytosis, what does the bone marrow biopsy show? What does the blood smear show?

What translocation do you see?

 

What diagnosis does this lead to?

hypercellular bone marrow with mature granulocytes 

macrophages with blue green cytoplasm (Pseudo-Gaucher cells)

t(9;22) (BCR-ABL TK)

 

Chromic Myelogenous Leukemia 

12

How do we treat our pt with CML?

Imatinib 

It is a TK inhibitor 

Can monitor amount of BCR-ABL with cytogenics, FISH, or PCR to look at the molecular response to treatment 

also follow the hematologic response to treatment as well

13

Why is it important to monitor CML closely?

It can progress to a more aggressive state 

Two phases include: 

Accelerated Phase: circulating blasts 10-19% with thrombocytopenia and basophilia 

Blast Phase/crisis: blasts >20%

14

What about LAD makes you suspicious?

Subclavian/Supraclavicular nodes 

fixed/hard nodes

size greater than 4cm 

(tender is often benign) 

15

What are three ways that you can test LN when you find LAD?

Fine needle aspiration

Needle Biopsy

Excision Biopsy

16

What is a fine needle aspiration?

it is a liquid sample that can show metastatic cells or be used for flow cytometry to assess the clonal nature of the cells 

It is only used for NHL

17

What is a needle biopsy used for?

it examines a solid core of tissue and can pull out metastatic cells or be used for flow cytometry 

18

What is an excisional biopsy used for?

Best way to diagnose lymphoma and the ONLY way to diagnose HL via Reed-Sternberg cells 

19

14y/o f pt with abdominal pain in RLQ. CT shows mass adjacent to appendix. Pt started on Abx for presumptive appendicitis. Repeat CT 2 days later shows increased mass size. Pathology shows Burkitt Lymphoma. What would further pathology reports show? 

Is there any metastasis?

What is the treatment? 

MYC translocation of t(8;14) 

WORST lymphoma translocation 

intracranial mass and bone marrow involvement (CNS and BM involvment more likely with Burkitt's than other NHL)

chemo with intrathecal admin. 

20

In our pt with Burkitt's Lymphoma, urine output decreases after chemotherapy initiation. What does her labwork show and why is this happening?

 

How do you treat? 

Increase in plasma K, serum creat. and BUN

this is indicative of Tumor Lysis Syndrome

Treat with aggressive hydration

 

(the tumor burden and high response to chemo increases risk for TLS) 

21

22 y/o male with fatigue, chest pain after ETOH consumption, night sweats and fever, pruritis, weight loss, no LAD or splenomegaly. Because of these B symptoms you do what type of test?

What does the pathology show? 

What does this inidicate? 

How do you treat it?

Excision biopsy of chest mass seen on imaging

Path shows Reed-Sternberg cells 

Indicates a HL 

Treat with chemo and mayne some radiation 

22

When it comes to HL, what are three common ways of presentation?

LAD

B-symptoms (can be in NHL)

Mass on chest x-ray 

(may be limited to mediastinal mass that produces minimal or no local mass effect sx)

23

Pt is an older male with conjunctival pallor, petechiae, and axillary/cervical LAD. 

What do labs show?  

What is the diagnosis?

slightly elevated WBC, low Hgb, decreased PLT

Blood smear shows 90% small lymphocytes

Flow cytometry shows monoclonal B cells

Dx: CLL/SLL 

24

In our pt with CLL/SLL, his wife mentions that he was diangosed with CLL many years ago and told to return for monitoring, but he did not do so. REcords show that 6yrs ago, he had CLL present without anemia or thrombocytopenia. Now that he has new cytoppenias, what does this mean for the progression?

There is now bone marrow involvement indicating acceleration of the dz. 

This can become Richter's Transformation

25

13 y/o f with hx of menorrhagia, easy bruising, scrapes take a long time to stop bleeding, occasionally nose bleeds 1-2x per month. Dad with similar hx. 

What do labs show?

What is the diagnosis?

How to treat? 

Bonus genetics? 

low hgb, normal PLT

PTT prolonged, PT normal 

vWF ag: decreased

vWf: decreased 

Factor VIII: normal 

Dx: vWF Disease Type I

Tx: Desmopressin to help release vWF 

Bonus genetics: 1, 2a and 2b are AD

26

6 y/o m with oral bleeding after dental procedure, hx of of easy bruising from minor trauma and bleeding into joints

Labs show?

Diagnosis?

Genetics? 

Treatment?

normal PT, prolonged PTT

Factor XIII: only 3% normal activity 

Factor IX: 98% normal activity

geneitc test for Hemophilia A: positive

X-linked recessive 

Recombinant Factor XIII

27

What can an abnormal aPTT alone indicate?

if bleeding: VIII, IX, XI defects 

no bleeding: XII, prekalikrein, kininogen, lupus, anticoagulants 

28

What does an abnormal PT alone indicate? 

VII defect

29

What does an abnormal PT and aPTT together indicate? 

anticoagulant therapy, DIC, liver disease, K deficiency, massive transfusion

rarely factor X, V, II defects 

30

32y/o female with recurrent vaginal bleeding 6wks post partum with epistaxis and fatigue. Family history of autoimmune disease. 

Exam shows: 

Labs show: 

What should we further test? 

How do we treat? 

ecchymosis, pallor, hypotension and tachycardia, vaginal bleeding 

anemia with normal PT and prolonged PTT that was not corrected with mixing study (therefore it isn't a factor issue) 

Test for antibodies. Negative Lupus/heparin, positive factor VIII inhibitor

fluids, factor VIII and factor VIIA bypass and immunosupression