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Welcome to clinical presentation

Presented by…

Dr. Nazia Sharmin

Resident, Phase B

Dept of haematology

BSMMU.

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A 29 year old male patient presented with fever and abdominal lump for 1 month.

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  • Mr. Fakrul Islam-29-year old male, 2nd issue of non consanguineous marriage hailing from dhaka got admitted to haematology department, BSMMU on 27th july with the complaints of-,
  • Fever for 1 month
  • Feeling of lump in the left upper abdomen for same duration

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  • According to the statement of the patient he was reasonably well 1month back. Then he developed fever which was-
  • High grade
  • Highest recorded temp was 103˙F
  • Not associated with chills and rigor, night sweats.
  • Partially subsided after taking paracetamol.

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  • He also feels a lump in the left upper abdomen which is gradually increasing, associated with heaviness and occasional dull pain for 1 month. But for the last few days the intensity of pain increases and it also radiates to the whole abdomen, not associated with any aggravating or releaving factors..
  • Also complaints of loss of appetite, poor effort tolerance, exertional dyspnoea.
  • He is constipated for last 7days.

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intensity

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  • On query he gave history of weight loss about 10kg with in last 3 months.
  • There is no history of cough, hemoptysis,respiratory distress, contact with TB patient, gum bleeding or bleeding from any other site of the body.
  • No history of travelling to malaria endemic area.
  • He is not a resident of kala-azar endemic area.
  • Bladder habit is normal.

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  • With all these complaints patient consulted a physician and treated conservatively. As there was no improvement he was referred to the hematology dept of BSMMU.

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Examination ..

  • On general physical examination….
  • Conscious
  • Co-operative
  • Anaemic
  • No jaundice, cyanosis
  • pulse : 95 b/min
  • BP :130/ 80 mmhg
  • Temp: 101 ̊F
  • No lymphadenopathy
  • Skin condition: normal, no bleeding manifestationor hyperpigmentation.
  • Bony tenderness: absent

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Systemic examination…

  • Abdomen :
  • Massive tender spleenomegaly about 16 cm from the left costal margin in the anterior axillary line towards the right iliac fossa, firm in consistency, tender, rounded margin, smooth surface, moves with respiration, no splenic rub present.
  • No other organomegaly
  • Bowel sound normal.
  • Examination of the other system reveals no abnormality.

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Provisional diagnosis…

  • Acute Leukaemia
  • D/D:
  • Lymphoma.
  • Chronic Kala-azar
  • Chronic malaria.
  • Disseminated TB

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Investigations …

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CBC

​

Hbg/dl

ESR

WBC

PLATELET

MCV

MCH

14/7/21

13.4 g/dl

07

3.0x10^9/l

160x10^9/l

87 fl

29pg

25/7/21

10.7g/dl

35

1500/cumm

150x10^9/l

75 fl

25pg

28/7/21

10g/dl

15

2.50x10^9/l

215x10^9/l

81 fl

30pg

30/7/21

9g/dl

37

3x10^9/l

110x10^9/l

81 fl

25pg

31/7/21

9g/dl

28

3.47x10^9/l

97x10^9/l

81 fl

25pg

02/8/21

7.9g/dl

28

2.64x10^9/l

103x10^9/l

81fl

25pg

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PBF

  • RBC : anisochromia with dimorphic and few target cells.
  • WBC : mature with reduce number of leucocytes
  • Platlets : normal
  • Comments: bicytopenia.

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15/7/21

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  • ICT for P.falciparum Ag : negative
  • ICT for P. Vivax Ag : negative
  • ICT for Kala Azar Ab IgG : negative
  • ICT for Kala Azar Ab IgM: negative

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28/7/21

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  • S bilirubin : 0.59 mg/dl
  • PT : 15 sec
  • APTT: 30 sec

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30/7/21

  • S. Electrolytes:
  • Na : 137 mmol/l
  • K : 3.9 mmol/l
  • Cl : 105 mmol/l
  • SGPT : 50 u/l
  • SGOT : 120u/l
  • S. creatinine :1.25 mg/dl

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1/8/21

  • CRP: 299mg/l
  • Procalcitonin : 0.287µg/l
  • RBS : 5.0 mmol/l
  • Uric Acid : 9.9 mg/dl
  • Albumin : 37g/l
  • Total protein : 53 gm/l

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  • S. Ferritin : 739.4 ng/mL
  • S . LDH : 1087.0 u/l
  • Coomb’s test :negative.

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2/8/21

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  • Anti dengue IgM : negative
  • Anti dengue IgG : negative

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  • Blood for C/S : no growth of the bacteria.

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Bone Marrow examination …17/7/21

  • Hypercellular marrow with decrease M/E ratio.
  • Erythropoesis is hyperactive and normoblastic

With megaloid changes..

  • Granulopoiesis is active , shift to left and 12-15 % marrow nucleated cells are myeloblast.
  • Megakaryocytes are normal in number and morphology.

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  • Comments: Features are consistent with Refractory anemia with excess blasts( RAEB-2)
  • Advice: Immunophenotyping of acute Leukaemia panel

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Bone marrow…

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Histocytes in normal BM.

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What is the Final diagnosis?

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  • ?MDS (RAEB2)
  • ?Lymphoma
  • ?Storage disease.

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Next plan..

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  • Image guided intra abdominal Lymph node biopsy / splenic biopsy
  • FISH for MDS
  • Beta glucoserebrosidase enzyme..pending

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Thank you