NYU Medicine Grand Rounds Clinical Vignette

NYU Medicine Grand Rounds Clinical

Vignette

Maryann Kwa, MDPGY-2

January 12, 2011

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.

Chief Complaint


• 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˚.

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.

History of Present Illness


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


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 normalUNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Laboratory Findings

• CBC: • Hemoglobin/Hematocrit 9.0/27

• MCV 87 • Platelets 256

• White blood cell count 11.0


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)


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


Acute myeloid leukemia, versus chronic myeloid leukemia with blast crisis, versus lymphoma

Differential Diagnosis


Additional Laboratory Studies

• Lactate dehydrogenase: 502 (110-225 U/L)

• Haptoglobin: 435 (30-200 mg/dL) • Reticulocyte %: 1.99 (0.5-1.5)


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


CAT Scan Chest


• Hospital Day 1:– Bone marrow biopsy was performed.– Flow cytometry and cytogenetics were sent.

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)].

Hospital Course


• Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21

Revised Working Diagnosis


• 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.

Hospital Course


• A repeat bone marrow biopsy showed complete remission after induction chemotherapy.

• The patient is currently awaiting consolidation therapy.

Outpatient Course


• Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21, responsive to induction chemotherapy, now in complete remission.

Final Diagnosis


NYU Medicine Grand Rounds Clinical Vignette

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