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 PATIENT CASE HPI J.O. is a 5 yo girl who is brought to the
pediatric clinic by her mother. Mrs. O. reports that, for the
past week, her daughter has been very tired, lacks energy,
sleeps more than usual, and has not had much of an appetite.
Furthermore, there are unexplained bruises on her arms and
legs. -LPMH J.O. was a full-term infant from an
uncomplicated pregnancy and delivery. All immuniza tions
are current. She has had only one childhood disease-measles,
at age 2 years FH The patient has one brother, age 3 years,
who is in apparent good health. The family history is

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unremarkable with one exception: The paternal grandmother

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died at age 62 from gastric cancer. J.O, has not been exposed

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to ionizing radiation. The patient's developmental milestones
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are on target. She can tie her shoes, print her own name, and
likes to help with household tasks. ROS Deferred - Meds
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None 406
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All NKDA PE and Lab Tests Gen Alert, interactive, but ill
appearing white child Patient's height and weight seem
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normal for a 5-year-old VS See Patient Case Table 85.1

Patient Case Table 85.1 Vital Signs Systolic blood pressure
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109 mm (94-109 mm) Diastolic blood pressure - 67 mm (56-

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69 mm) HR - 130/min (70-115/min awake) RR - 20/min (17-

27/min) T-98.6 � F (98.3-98.6 � F) HT-41 inches (41-43
inches) WT-37 lbs (40-50 lbs) "Reference vital signs
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appropriate for a 5-year-old girl are provided in parentheses

Patient Case Question 1. Suggest a reasonable cause of
tachycardia in this patient. Skin Very pale, warm, and dry

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 Ecchymoses on extremities, over the buttocks, and lower left
flank area No rashes HEENT Head is normocephalic and
atraumatic Pupils equal al 3 mm, round, and reactive to light
and accommodation Extra-ocular muscles intact Tympanic
membranes clear and intact Nares are clear bilaterally Throat
is without redness or soreness Petechiae of mucous
membranes in oral cavity Dental development consistent with
age: has incisors, cuspids, and Ist and 2nd molars, no

Patient Case Question 2. Explain the enlarged lymph nodes in

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this patient. Lungs/Chest Clear to auscultation bilaterally

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without crackles or wheezes Good ventilation throughout

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Cardiac Heart rate and rhythm normal and without murmurs
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Abd � Soft and non-tender without distension � Good
bowel sounds No masses - Liver and spleen are enlarged
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Patient Case Question 3. Explain the patient's enlarged liver

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and spleen. Genit/Rect No tenderness, bruising, or blood

observed MS/Ext Mild adenopathy in the inguinal region
bilaterally Femoral pulses are 2+ bilaterally Extremities show
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no cyanosis, clubbing, or edema � No bone or joint pain

elicited by palpation Neuro � No dysmorphic features �
Fixes and follows well with conjugate eye movements �
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Hearing is within normal limits � Motor exam shows 5/5

muscle tone in all extremities � Gait is normal Cranial
nerves intact � Deep tendon reflexes present and equal at 2+
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Facial muscles symmetric and normal

Patient Case Table 85.2 Laboratory Blood Test Results 7.1

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 g/dLAST Het 21% ALT RBC 2.9 million/mm Total bilirubin
WBC 12,800/mm Total protein � Neutrophils 591 Alb �
Lymphocytes ca 26% � Monocytes Phos . Eosinophils Uric
acid � Basophils lasts 10 PTT Glucose, fasting 28,000/mm!
80 IU/L 103 IU/L 0.8 mg/dL. 6.9 g/dL 3.5 dl 9.2 mg/dl. 4.0
mg/dl. 4.3 mg/dL 13 sec 25 sec 90 mg/dl. PT Ple Patient Case
Question 4. Why might this patient's AST and ALT
concentrations be abnormal? Other Tests J.O. was
immediately referred to a pediatric oncologist and admitted
to the children's hospi. tal for further workup. Bone Marrow

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Aspirate . 93% blasts, 3% erythroblasts, 4% all other cells �

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RT-PCR: (+) for TELAMLI fusion gene with no other

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cytogenetic abnormalities Chest X-Ray Normal with no
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mediastinal mass
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Chest X-Ray Normal with no mediastinal mass Lumbar

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Puncture � Spinal fluid clear and colorless � Opening

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pressure 90 mm H,O � Glucose 50 mg/dL � Total protein

18 mg/dL � No blasts present Immunology (+) for
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cytoplasmic pa heavy-chain proteins Patient Case Question 5.

What is the significance of this patient's spinal tap? Patient
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Case Question 6. Which type of acute lymphoblastic

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leukemia does this patient have? Patient Case Question 7.

Can this patient's prognosis be characterized as very
favorable, fair, or poor?
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- Clinical Course On the 2nd day following admission, J.O.

was treated with irradiated/filtered platelets, packed red

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 blood cells, and allopurinol. Patient Question 8. Why was the
patient treated with allopurinol prior to intensive
chemotherapy? Day 3 Remission Induction Therapy Orders
Prednisone 1 mg IV wk X 4 Vincristine 1 mg IV Q wk X 4
Asparaginase 3,600 units IM on chemotherapy days 3, 6, 9,
13, 16, 20 Intrathecal therapy with methotrexate on
chemotherapy days 3 and 17 Patient Case Question 9. Why
was intrathecal therapy begun when the patient had no
clinical signs of leukemia in the central nervous system?

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