Acute leukemia

張貼日期：2018/7/8 上午 04:07:48

A 62 y/o F

[Major past history]

[History summary & assessments]

According to patient and her family, this is a patient with lymphoma, refractory to multiple lines of chemotherapy at Taichung(中國醫藥大學附設醫院). PBSCH with Mozobil was arranged few days ago. However, severe leukocytosis (up to 260k/uL) was noted after Mozobil injection. The patient was referred to our ER on 2017/9/8. We were consulted for further evaluation.

[PE]

GCS: E4V5M6

HEENT

Head: trauma (-), scar(-)

Eye& Ear: pale conjunctiva (-), icteric sclera (-)

Mouth: petechiae(-), thrush(-)

Neck: supple, lymph adenopathy (-), jugular vein engorgement(-)

Axillary lymph nodes (-)

Chest

Inspection: symmetric expansion, Accessory muscle exertion(-)

Auscultation: bilateral clear, wheezing(-)

Abdomen

Inspection: soft, globular, caput medusa(-), petechiae(-)

Auscultation: bowel sound(hypo-active)

Palpation: peritoneal sign(-), tenderness(-), hepatomegaly(-), splenomegaly(-), mass(-)

Percussion: normo-tympanic, No shifting dullness

Limbs: cold, edema(-), decreased arterial pulsation(-)

Skin: Skin turgor fine, petechiae(-), ecchymosis(-)

[Hemograms]

WBC(4.49 K/μL) HB(6.7 g/dL) PLT(95 K/μL) Normoblast(65 /100) Blast(16 %) Promyl.(3.0 %)

Myelo.(4.0 %) Meta(1.0 %) Band(1.0 %) Seg(7.0 %) Eos.(0 %) Baso.(0 %)

Mono.(29 %) Lym.(39 %) Aty.Lym.(0.0 %) PlasmaCell(0 %)

[Biochemistry]

CRE(0.9 mg/dL) Na(132 mmol/L) K(3.5 mmol/L) LDH(U/L) Uric acid( mg/dL)

Bil-T( mg/dL) Bil-D( mg/dL) ALT(6 U/L) Alb(2.0 g/dL)

PB smear: many immature large cells with cytoplasmic granules, favor myeloid blasts

1. Acute leukemia, favor myeloid leukemia

1. Component therapy with 減白加電血品 to keep Hb > 8.0 and PLT > 20K if no active bleeding

2. Check LDH, uric acid, Na, K, Ca, Mg, P, PT/PTT, fibrinogen, HBsAg, Anti-HBs, Anti-HBc, Anti-HCV, HIV combo test

3. Give normal saline 1000ml QD, cash feburic 0.5# QD for hyperuricemia and prevent tumor lysis syndrome

4. Give Rasburicase 0.15mg/kg/dose (大概BW/10支,用前跟VS說) if uric acid > 10 mg/dL

5. We would arrange hematology ward admission soon.

AML:

• If WBC > 100 k/μL or symptomatic hyperleukocytosis(dyspnea, headache, blurred vision, focal neurologic sign) is present, consider leukapheresis(照會檢驗醫學部)
• Give Hydrea 2# BID~QID(maximal: 80mg/kg/day) if high risk of leukostasis

ALL:

• Give solu-medrol 1mg/kg/day for cytoreduction

APL:

• Component therapy keep Plt > 50k/uL, fibrinogen > 150 mg/dL
• If WBC > 10k/μL, consider give Hydrea(20-80mg/kg/day)
• Give vesanoid 3-4# BID(45mg/m2/day)
• If ATRA syndrome is concerned, give prophylatic prednisone 0.5mg/kg/day or dexamethasone 10mg q12h
• If ATRA syndrome is suspected, give dexamethasone 10mg q12h