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Doczilla
07-11-2009, 17:33
Another case. Photographs were obtained with the patient's permission with the understanding that they will be published for medical education discussion. Do not disseminate the photos.

21 yo M presents to the ED with a complaint of nausea, vomiting, and epigastric pain. He also complains of fatigue. He had seen his PCM one week prior for a painful lesion of the tongue, for which he was prescribed prednisone liquid for suspected apthous ulcer. He started having burning epigastric pain and nausea for 3 days prior to his ED visit, and started having nonbilious nonbloody vomiting the day prior to the ED visit. He denies diarrhea, and states he has been moving his bowels normally. No hematochezia (bright red bleeding in the stool) or melena (black tarry stools). He went to the urgent care, where he was evaluated and sent to the ED for further workup. The urgent care doc called ahead and mentioned that he was concerned about a petechial rash on the patient's face. The patient's tongue lesion has not improved with treatment.

He is a healthy M with no significant medical history. He has never had surgery. He takes no medications or supplements other than the prednisone liquid he was prescribed a week prior. He denies smoking or drug use. He endorses occasional social alcohol use, which he describes as 2-3 12oz beers on the weekend. He is sexually active with one partner for several months.

Review of symptoms:
No fever, chills, or cough. No difficulty breathing. No headache. He complains of mild lightheadedness on standing. No headache or stiff neck. No visual disturbances. No back pain. No dysuria, penile discharge, or testicular pain. No edema. No focal neurological complaints.

His vitals are as follows:
T 98.8 Pulse 89 Resps 16 BP 112/68 SaO2 97% on room air.
On physical exam, the patient appears to be in no acute distress.
Lips are pale. There are subconjunctival hemorrhages in both eyes. EOMI and PERRL.
There is a fine petechial rash below both eyes, on the soft palate, and behind both ears. The rash is nontender.
A 4mm lesion is noted on the left lateral edge of the tongue. It is moderately tender and exhibits a white coating over an erythematous base. The white coating cannot be scraped off. No other similar lesions are noted.
The neck is supple. No JVD. No lymphadenopathy.
Heart sounds reveal a regular rate and rhythm, clear S1 and S2 with no murmurs, rubs, or gallops.
Lung sounds are clear and symmetrical bilaterally with good air movement. The chest is nontender.
Abdomen is soft, nondistended. He is minimally tender to palpation in the epigastric region with no percussion tenderness, rebound tenderness, or peritoneal signs. Rectal exam is nontender revealing brown guiac positive (fecal occult blood test) stool
GU exam is unremarkable. Normal external male genetalia, no hernias, nontender exam, and no lymphadenopathy.
Extremities reveal no rash or edema. Weak symmetrical pulses bilaterally.
Neuro exam is unremarkable. 5/5 strength in all extremities, cranial nerves 2-12 and cerebellar function are intact.

Chest xray reveals no abnormality by my read.
EKG reveals a normal sinus rhythm, no ectopy, normal axis, normal ST segments and T waves, and no abnormality.
CBC is significant for the following: WBC 3 (normal 4-10), Hgb 5 (normal 12-15), platelet count 7k (normal 150k-400k). Mean cell volume is increased at 110.
BMP, LFTs, Lipase are normal. PT and PTT are normal. Urinalysis is significant for a small amount of blood, but no sign of infection. ESR is markedly elevated at 70.

The patient was hydrated with IV fluid. He was placed in reverse precautions since we were concerned about his susceptibility to infection. Type and cross were obtained and he was transfused packed RBCs and Platelets. He was admitted to the bone marrow unit, which has special infection control procedures, since patients on that floor are immunosuppressed.

His subsequent testing revealed the following:
HIV, Hep B and C were negative. Blood cultures and urine cultures had no growth after 5 days. Echocardiogram was normal. Herpes PCR of his tongue lesion were obtained. LP was performed, and was negative for bleeding, infection, or viral PCR. He was also started on acyclovir for suspected herpes infection of his tongue. He was given IV Nexium for GI bleeding.

Final diagnosis:
Bone marrow aspiration revealed acute myelogenous leukemia. A medi port was placed in his chest so he could begin chemotherapy. The patient is maintaining an unflinchingly positive outlook, and is genuinely liked by every staff member who meets him.

Learning points:
AML is not a diagnosis that anyone makes in the ED. A prudent workup and high index of suspicion will ensure that danger signs are not missed and the patient is referred for appropriate follow up testing.
He was pancytopenic. He is anemic not only from poor production, but also GI blood loss. His low level of WBCs makes him immunosuppressed, so use good infection control procedures.
Platelet transfusion is usually considered in concert with a hematologist, but with bleeding complications and a plt count below 25K, nobody will fault you for doing it.
This guy was dangerously anemic, but showed no alteration in his vital signs. His pallor was the only clue to his anemia. Young healthy patients can mask really horrible problems by compensating well.
Obtain an EKG in suspected severe anemia. Any indication of strain or ischemia should prompt immediate transfusion.
Beware the petechial rash. Consider things like viral infection, meningococcus, septic emboli from endocarditis, idiopathic thrombocytopenia purpura, vasculitis like kawasaki's disease (usually young children), henoch-schoenlein purpura, Rocky Mountain Spotted Fever, leukemia, and other really bad things.
Sometimes, bad stuff happens to good people for no reason at all.

'zilla

frostfire
07-12-2009, 00:32
great case, although my heart still sank when I got to :

Bone marrow aspiration revealed acute myelogenous leukemia.



Learning points:
AML is not a diagnosis that anyone makes in the ED. A prudent workup and high index of suspicion will ensure that danger signs are not missed and the patient is referred for appropriate follow up testing.
He was pancytopenic. He is anemic not only from poor production, but also GI blood loss. His low level of WBCs makes him immunosuppressed, so use good infection control procedures.
Platelet transfusion is usually considered in concert with a hematologist, but with bleeding complications and a plt count below 25K, nobody will fault you for doing it.
This guy was dangerously anemic, but showed no alteration in his vital signs. His pallor was the only clue to his anemia. Young healthy patients can mask really horrible problems by compensating well.
Obtain an EKG in suspected severe anemia. Any indication of strain or ischemia should prompt immediate transfusion.
Beware the petechial rash. Consider things like viral infection, meningococcus, septic emboli from endocarditis, idiopathic thrombocytopenia purpura, vasculitis like kawasaki's disease (usually young children), henoch-schoenlein purpura, Rocky Mountain Spotted Fever, leukemia, and other really bad things.
Sometimes, bad stuff happens to good people for no reason at all. true :(

'zilla

Excellent learning points esp. on compensation. Reminds me of cases with high (as in 210+) systolic BP and the person was having no problem at all.

Based on his symptoms (and assuming a busy ED), I would not have considered neuro consult at all. What were you trying to rule out, Doczilla?

Thanks for the education

Doczilla
07-12-2009, 02:31
There was no neuro consult. LP was performed by medicine after admission. No way would I stick a needle in his back with that platelet count. I didn't feel the need to get it either. Presumably they did it as part of the workup for infection (syphilis, viruses) but I don't really know.

'zilla

PedOncoDoc
10-29-2009, 09:38
I'm not one to resurrect an old thread, but this is my AO and wanted to give my $.02 on the matter.

If more than 2 cell lines (WBC's, Hgb, Plts) are down, marrow failure or replacement/infiltration needs to be high on your index of suspicions. This would include aplastic anemia, acute leukemia, other cancers metastatic to the bone marrow and a smattering of other bone marrow failure syndromes that can be teased out by the Heme/Onc doc. We all know to think of leukemia with an extremely high white count, but 2 or more cytopenias are another common presentation.

An LP should be performed under controlled circumstances if a diagnosis of leukemia is made and no sooner unless deemed absolutely medically necessary. Chemotherapy is given intrathecally with the first/diagnostic/staging LP in acute leukemia, so this will typically be performed by the oncologist. Regardless, an LP should not be performed with a platelet count less than 50k and transfusions will be administered to raise the platelet count to that level. These patients typically do not need platelet transfusions in the ED unless they have active bleeding. In some cases of AML, namely in M3, there is also a coagulopathy that requires factor replacement (i.e. FFP). Coag's should be performed on patients with this presentation to assess for coagulopathy and replacement should be given if needed, but gaain, need not be administered emergently in the ED without active bleeding.

AML in this age group, barring certain prognostic factors such as high-risk cytogenetics, has an overall survival rate of >60%. In the US, when available, patients <25 years old will often be treated on pediatric protocols because they tend to have better outcomes when they do. Those who do not maintain a durable remission are eligible for bone marrow transplantation from relatives or unrelated donors.

I hope all goes well for this gentleman. I know all too well what he is going through.