PHYSICIAN CONFERENCE

MAY 2022
TOPIC : A CASE OF NEUTROPENIA
UNIT -5

CHIEF:PROF.DR.C.MANOKARAN
• 50 year old female presented with complaints of Fever on and off
since one month.
• H/o Recurrent episodes of fever for past 1 year.
• H/o Cough with Expectoration since 15days
• H/o B/L Lower limb pain for 2 days
• H/o 1 episode of vomiting ( contains food particles, Non bilious,Non
blood stained ) since 1 day.
• No h/o chest pain, palpitation, syncope
• No h/o abdominal pain, loose stools
• No h/o Breathlessness
• Consumes mixed diet
• On examination:
• Patient Conscious , Oriented , Febrile
• Pallor present
• B/L Inguinal lymphadenopathy (size 2x2cm,non tender, non mated)
• No cyanosis, clubbing, pedal edema
• HR: 120/min: BP:80/?mm Hg, SPO2- 86%@ room air
• JVP: not elevated
• SYSTEMIC EXAMINATION
CVS: S1S2 present, no murmurs
RS: B/L Air entry equal, intra scapular and infra scapular crepitations
present
Abdomen: Soft , nontender .
liver palpable 2-3cm below right costal margin
Spleen tip palpable
CNS: GCS 15/15
B/L Pupils equal and reacting to light
B/L plantar flexor
 22-04-22
Haemoglobin 8.9 gm/dl
PCV 26.5%
RBC 2.6millions/mm3
MCV 99.7 fl
TLC 200 cells/mm3
Poly 21%
Lymph 45%
Eoso 04%
Mono 30%
Platelets 138000
ESR ½ hr
1 hr
WBC Differential count
 22-04-22 23-04-22

RBS 131 mg/dl 124 mg/dl

Urea 35mg/dl 42 mg/dl

Creatinine 2.0mg/dl 2.3 mg/dl

Sodium 142 meq/l 138 meq/l

Potassium 3.0 meq/l 4.9meq/l

Chloride 100 meq/l

 Arterial Blood Gas (ABG) 22-04-22
Metabolic acidosis with respiratory alkalosis
pH 7.45

PCO2 24.0 mmHg

PO2 158mmHg

HEMATOCRIT 25%

CHC03(PT) 16.3

CHCO3 19.1

ANION GAP 19.3

Liver Function Test 22-04-22

Total Bilirubin 0.9mg/dl

Direct Bilirubin 0.3 mg/dl

SGOT 43 IU/L

SGPT 51 IU/L

Alk. Phosphatase 81 IU/L

Total protein 7.8 g/dl

Albumin 4.3 g/dl

GGT 50 U/L

Serum Osmolality 307 mOsm/kg

• Dengue NS1 Antigen - ELISA- Non Reactive
• Dengue IgM Antibody- ELISA- Non Reactive
• Scrup Typhus IgM Antibody – ELISA – Non Reactive

• HIV Antibody: Non Reactive

• HBsAg : Non Reactive
• HCV : Non Reactive
 23-04-22

Absolute Eosinophil Count (ACE) 20 cells/cu.mm

Fibrin Degradation Products Positive

PT 15.3 sec

INR 1.1

D dimer 1.49 ug/ml

Ionised Calcium 1.12 mmol/l

 22-04-22

Spot urinary potassium 61.8mEq/L

Urine Osmolality 310.8 mOsm/kg

CT Thorax showed – Tubular and cystic
bronchiectasis with centrilobular nodules.
Provisional Diagnosis:

1)SEPSIS /SEPTIC SHOCK-? FOCI

2)PANCYTOPENIA UNDER EVALUATION-? ACUTE LEUKEMIA

3)ACUTE KIDNEY INJURY- eGFR-26ML/MIN /1.73M2

 23-04-22

Haemoglobin 9.1 gm/dl

PCV 27%

RBC 2.71millions/mm3

MCV 99.7 fl

TLC 1600 cells/mm3 (On smear)

Poly 06%

Lymph 26%

Eoso 01%

Mono 30%

Platelets 135000

ESR ½ hr 12
1 hr 20

WBC Differential count Blast-62%,Metamyelocyte-03%

PERIPHERAL SMEAR
• 1) RBC-Macrocytic normocytic red cells with mild Aniso
poikilocytosis.
• 2) WBC- Leucopoenia with increased blast cells showing high N:C
ratio, hyperchromatic nuclei and Auer rods.
• DC: Blast-62%,Metamyelocytes-03%,Band forms-02%,Neutrophils-
06%,Lymphocyte-26%,Eosinophils-01%
• 3) Platelets – decreased.
• 4) Hemiparasites – Negative

Impression – ACUTE MYELOID LEUKAEMIA.

FINAL DIAGNOSIS

• 1) ACUTE MYELOID LEUKEMIA

• 2) SEPSIS -LRTI

• 3)DISSEMINATED INTRAVASCULAR COAGULATION

• 4)ACUTE KIDNEY INJURY

Treatment given :
• Inj Noradrenalin 4ML in 46ML NS @ 6ml/Hr
• Inj Meropenam 500mg I/V BD
• T Azithromycin 500mg OD
• Inj Pantop 40mg I/V BD
• Syp KCL 15ml in 30ml in water TID
• Neb Budecort
• Neb duolin
• T Dolo 650 mg TID
 ACUTE MYELOID LEUKEMIA
(AML)
Clonal malignancy of myeloid bone marrow precursors in which poorly
differentiated cells accumulate in the bone marrow and circulation.

• Symptoms occur because of the absence of mature cells normally

produced by the bone marrow like
• Low granulocytes ( ↑susceptibility to infection)
• Low platelets ( ↑susceptibility to bleeding). 
• A preleukemic syndrome may be present in some 25% of pts with AML. 

• Most common Signs would be anemia, pallor, fatigue, weakness,

palpitations, and dyspnoea on exertion.

• White blood cell count (WBC) may be low, normal, or markedly elevated

• Anorexia and weight loss are common; fever may be present.

• Hepatosplenomegaly occurs in about one-third of patients.

• Leukemic meningitis may present with headache, nausea, seizures,
papilledema, cranial nerve palsies.

• Metabolic abnormalities may include hyponatremia, hypokalemia, elevated

serum lactate dehydrogenase (LDH), hyperuricemia, and (rarely) lactic
acidosis .
• The most common abnormality is DIC which results in elevated PT,
decreasing fibrinogen level, and presence of fibrin split products

• In case of very high blast cell count in the blood, spurious hyperkalemia and
hypoglycaemia may occur (potassium released from and glucose consumed
by tumor cells after the blood was drawn).
• Acute Promyelocytic leukemia is also known as M3, which is the most
common subtype of AML which is associated with DIC.
Diagnosis
• Complete blood picture with Peripheral Smear .

• Bone marrow aspiration and biopsy.

• The  presence of at least 20% blasts in the bone marrow or peripheral smear is
diagnostic of AML.

•  Flow cytometry, cytogenetics, and fluorescence in situ hybridization (FISH). 

• The presence of Auer rods (clumps of azurophilic granules resembling

elongated needles) is diagnostic of AML.
Treatment / Management
• About 60–80% of pts will achieve initial remission when treated with cytarabine 100–
200 (mg/m2)/d by continuous infusion for 7 days, and daunorubicin (45 [mg/m2]/d) or
idarubicin (12–13 [mg/m2]/d) for 3 days.

• Addition of etoposide may improve Complete Remission duration. Half of treated pts
enter CR with the first cycle of therapy, and another 25% require two cycles. About 10–
30% of pts achieve 5-year disease-free survival and probable cure.
• Patient achieving a CR who have low risk of relapse (cells contain t[8;21] or inv[16])
receive 3–4 cycles of cytarabine.

• Those at high risk of relapse may be considered for allogeneic bone marrow
transplantation.
Thank you