Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

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Clinical Correlations The NYU Internal Medicine
BlogA Daily Dose of Medicine
http//clinicalcorrelations.org
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Medical Grand RoundsClinical VignetteDecember
10, 2008

• By
• Alexandra Guillaume, MD

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Chief Complaint

• The patient is a 38 year old Fukienese speaking
  male who presents to the walk-in clinic
  complaining of 6 months of fevers, night sweats
  and gingival bleeding.

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History of Present Illness

• 6 months prior to presentation, the patient
  started noticing fevers, night sweats and
  gingival bleeding
• He tried various Chinese Herbal remedies which
  did not improve his symptoms
• Over the prior 6 months, he noted an approximate
  20 pound weight loss
• He denied any bleeding from other sites

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Additional History

• Past Medical History none
• Past Surgical History none
• Family History none
• Social History no toxic habits, immigrated from
  mainland China 6 years ago, currently unemployed
  and living with friends
• Allergies none
• Medications none
• Review of Systems non-contributory

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Physical Exam

• General thin, diaphoretic and poorly groomed
  Chinese male in no acute distress
• Vital Signs T-103 F BP-126/70 HR-96 RR-14
• HEENT poor dentition, dried blood over gums
• Skin cool and moist
• The remainder of the physical exam was normal

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Laboratory Findings

• CBC
• WBC 24 mm3
• Hemoglobin 10.6 g/dL, MCV 82
• Platelet 24 mm3
• Peripheral smear showed 35 blasts and 17
  promyelocytes with granules and auer rods
• Coagulation studies including fibrinogen were
  within normal limits
• Basic metabolic Hepatic panels were within
  normal limits

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Working Diagnosis

• Acute Myeloid Leukemia

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Clinical Course

• Because of the patients fever and high suspicion
  for leukemia, prior to the CBC returning, the
  patient was referred to the Emergency Room for
  admission.
• However, because the instructions were given to
  him via a translator that was not Fukienese (no
  translator was available at the time of the
  interview and so the interview was conducted in
  another Chinese dialect), the patient did not
  understand and instead returned home.
• Multiple attempts were made to contact the
  patient but because he was staying with friends,
  his phone number and address were incorrect and
  therefore the patient was lost to follow up.

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Clinical Course

• Three months later, the patient presented to the
  Walk-in Clinic because of worsening of his
  previously mentioned symptoms.
• He was escorted to the Emergency Room where he
  was admitted to the hospital
• On Hospital Day 1, a bone marrow biopsy was
  performed

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Bone Marrow Findings
Hypercellular marrow Trilineage hematopoiesis
with abnormal maturation Marked myeloid
hyperplasia withincreased immature forms ME
101 Dx Acute Myeloid Leukemia
Immunophenotypically c/w aPML, blast count 57
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Final Diagnosis

• Acute Pro-Myelocytic Leukemia