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WELCOME

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A 60-year-old female presented with fever and weakness

Dr. Khadiza Akter

MD Resident (Phase-A)

Green Unit

Department of Haematology

BSMMU

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Particulars of the patient

  • Name: Mrs. Shanti Begum
  • Age: 60 years
  • Sex: Female
  • Religion: Islam
  • Occupation: Housewife
  • Marital status: Married
  • Address: Madaripur
  • Date of Admission: 2th April, 2022
  • Date of Examination: 5th April, 2022

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Presenting Complaints

  • Fever for 2 months

  • Generalized Weakness for same duration

  • Multiple ecchymosis in different sites of the body for 1 month

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History of present illness

According to the statement of the patient, she was reasonably well 2 months back. Then she developed irregular on and off fever which lasted for 3-4 days, twice or thrice episodes in a month. Fever was low grade intermittent in nature, highest temperature was recorded 100°F. Fever was not associated with chills & rigor, night sweat & was subsided after taking antipyretic.

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History of present illness (cont’d..)

On query she gave history of generalized weakness for the same duration. Weakness was associated with palpitation & dizziness, for which she couldn’t perform her daily activities properly.

For the last 1 month she noticed multiple ecchymosis in front and back of the chest and legs.

She also developed a swelling in the lower part of the left arm for 7 days which was painful and for this reason there was difficulties in movement of the left elbow joint.

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History of present illness (cont’d..)

There was no history of headache, blurring of vision, , cough, hemoptysis & contact with TB patient, abdominal pain, burning micturition.

Her bowel & bladder habit is normal.

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History of Past illness

She is a known case of Diabetes mellitus for 6 years and Hypothyroidism for 1 year

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Treatment History

  • Patient was given symptomatic treatment for her illness
  • History of taking-

- Tab. Secrin (1mg)

- Tab. Thyrox (50 mcg)

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Family History

  • Patient has 1 son and 1 daughter. All of them are in good health

Personal History:

No history of betel nut chewing, smoking or taking alcohol.

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Immunization history

  • She is immunized according to EPI schedule. She gave no adult immunization history
  • Took covid vaccine

Menstrual history

  • Menopause – for 10 years

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Socioeconomic History

  • Lower middle socio-economic status
  • Monthly Income- 10,000 /- Taka
  • Education- Illiterate

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Physical examination

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General Examination

  • Appearance- Ill looking.
  • Body build- Below average
  • Cooperation- Cooperative
  • Decubitus- On choice
  • Nutrition- Poorly nutritious
  • Anemia- Moderately anaemic
  • Jaundice- Absent
  • Cyanosis- Absent
  • Clubbing- Absent

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General Examination(cont’d…)

  • Koilonychia- Absent
  • Leuconychia- Absent
  • Pulse- 76 b/p/m
  • BP- 110/70 mm hg
  • Temperature- 99℉
  • Respiratory rate- 20/min
  • BMI- 15.6kg/m2

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General Examination(cont’d…)

  • Edema- Absent
  • Dehydration- Absent
  • Skin- Multiple ecchymosis in front, back of the chest and legs

non pruritic, not palpable non tender and not blanch on pressure.

  • Lymph nodes- No lymphadenopathy
  • Thyroid gland- Not enlarged
  • Neck Veins- Not engorged

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Systemic Examination

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Musculoskeletal system

  • Look:

- There is a swelling in the lower 1/3 of the left arm

- Approx.. 5 cm * 1.5 cm in diameter

- Skin Color: Red

  • Feel:

- Local Temperature: Raised

- Tenderness: Grade – III tenderness

- Consistency: Firm. Not fixed with overlying skin or underlying structure

  • Move:

- Elbow joint: Restricted both active and passive movement

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Abdomen

Inspection:

  • Scaphoid in shape
  • Umbilicus is centrally placed and inverted
  • Flanks are normal
  • Horizontal scar mark in the lower abdomen, striae gravidarum present.
  • No visible peristalsis or any other pulsation
  • Hernial orifices are intact

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Abdomen(cont’d)…

Palpation:

  • Superficial:
  • Local temperature: normal
  • No tenderness
  • No rigidity

  • Deep:

Liver- not palpable

Spleen- not enlarged

Kidneys- not ballotable

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Abdomen(cont’d)…

Percussion:

Upper border of the liver dullness: right 5th intercostal space along the mid- clavicular line

No evidence of ascites (no fluid thrill, no shifting dullness).

Auscultation:

  • Bowel sound: present
  • No splenic rub
  • No hepatic bruit
  • No renal or aortic bruit

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Other system

Cardio-Vascular system

Respiratory system Reveals normal findings

Nervous system

Musculoskeletal system

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Salient Feature

Mrs. Shanti Begum, 60 yrs. Old housewife, diabetic,hypothyroid, normotensive hailing from madaripur presented with low grade intermittent fever for 2 months, twice or thrice episodes in a month. Each episode lasted for 3-4 days. Highest temperature was recorded 100°F & was not associated with chills & rigor, night sweat & was subsided after taking antipyretic.

She also presented with generalized weakness, palpitation & dizziness which are more even on mild activity.

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Salient Feature(cont’d)…

For the last 1 month, she noticed multiple ecchymosis in different parts of the body including front, back of the chest and legs.

She also developed a painful swelling in the lower part of the left arm for 7 days with impairment of flexion of the left elbow joint.

There was no history of taking any drugs or exposure to radiation or chemicals. Her bowel & bladder habits are normal.

There is no family history of bleeding disorder.

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Salient Feature(cont’d)…

On general examination, patient is moderately anaemic, all vitals are normal, multiple ecchymosis in front, back of the chest and legs which are of variable size and shape, painless,nonpalpable and do not blanch on pressure.

On systemic examination, there is a swelling in the lower 1/3 of the left arm approx. 5 cm * 1.5 cm in diameter which is firm, tender with impairment of flexion of the left elbow joint.

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���What will be the diagnosis ?��?????

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  1. Acute Leukemia
  2. Aplastic Anaemia
  3. ITP

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Investigations (Blood)

CBC with ESR

30/03/2022

4/4/2022

10/04/2022

Hb

8.8 gm/dl

7gm/dl

7.4gm/dl

ESR

50 mm in 1st hr

25 mm in 1st hr

20 mm in 1st hr

RBC

3,40,000

2,69,000

2,82,000

Platelet

50,000

1,10,000

50,000

TC

5,500%

3,300

3,500

Neutrophil

10%

24%

25%

Lymphocyte

45%

70%

70%

Monocyte

10%

4%

4%

Eosinophil

0%

2%

1%

Basophil

0%

0%

0%

Blast Cell

35%

-

-

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Investigations(cont’d…)

APTT

31.90 seconds

4/4/2022

Fasting B. glucose

10 mmol/L

3/4/2022

2 Hrs. after brakefast

8.5 mmol/L

3/4/2022

HbA1C

4.3%

3/4/2022

TSH

0.36 µIU/mL

3/4/2022

FT3

1.77 pcg/mL

3/4/2022

FT4

0.71 ngm/dL

3/4/2022

S. Albumin

1.1g/L

13/04/2022

S. bilirubin

0.3mg/dl

10/04/2022

HBsAg, Anti HCV

Negative

21/03/2022

HIV

Negative

21/03/2022

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Investigations(cont’d…)

S. Creatinine

0.81 mg/dl

10/04/2022

S.Calcium

6.9 mg/dl

10/04/2022

S. Electrolytes: Na

132 mmol/l

11/04/2022

K

4.9mmol/L

11/04/2022

Cl-

102 mmol/L

11/04/2022

T-CO2

15.3mmol/L

11/04/2022

SGPT

22 U/L

10/04/2022

RT-PCR for Covid-19

Negative

02/04/2022

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Bone Marrow examination report

Date: 22/03/22

Comment: Suggestive of Acute Myeloid Leukemia (AML)

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Flowcytometry

  • Date: 23/03/2022
  • Impression:
  • Immunophenotyping of the bone marrow aspirate by flow cytometry was done and onCD45 vs SSC gating, a predominent leukaemic cell population (78%) was identified in the low SSC and CD45 dim region with the following immunophenotyping profile: among myeloid marker CD13, CD33 and cyMPO were positive, CD64, CD14, CD117 were negative; among lymphoid markers CD10, CD7 were positive CD79a, CD20, CD3, CD4, CD19 were negative. Among other markers CD38, CD34, NuTdT were positive and HLA-DR were negative.

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Flowcytometry(cont’d)…

  • The overall Immunophenotypic findings are compatibles with Acute Myeloblastic Leukaemia(AML) with aberrant expression of CD7, CD10.

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Flowcytometry(cont’d)…

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Echocardiography(30/03/22)

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X-Ray left arm Both view

Comment: Normal Study (date: 09/04/22)

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Confirmatory Diagnosis

Acute Myeloid Leukemia (AML)

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Thank You