Welcome toClinical Meeting

Dr. Dhiman Saha

MD Part III

BICH

Particulars of the patient

• Name : Ronjila

• Age : 2 years 6 month

• Sex : Female

• Address : Bogra

• Date of admission : 02/11/16

• Date of examination : 03/11/16

• Informant : Mother

Presenting Complaints

• Fever for 1 month

• Progressive pallor for 1 month

History of Present Illness

According to the statement of informantmother, Ranjila was well 1 month back. Thenshe developed fever which was high gradecontinuous in nature (highest recordedtemperature was 1040 F), not associated withchills and rigor and subsided by takingantipyretics. Mother also noticed that her childgetting progressively pale and generalizedweakness for last 1 month. She had no historyof cough, vomiting, convulsion.

H/O present Illness (contd.)

She also had no history of taking anyoffending drugs, chemical exposure or eventraveling to endemic zone of kala-azar. Withthese complains her mother consulted withregistered physician and was treated with oralantibiotics, paracetamol syrup and referred toSZMCH. There she received blood transfusionfor single episode, then they took DORB andgot admitted to DSH for further evaluationand better management.

H/O present Illness (contd.)

As the condition was not improving, she was referred to DSH for further evaluation and better management.

History of Past Illness

There was no significant past illness.

Developmental History

Age appropriate

She was delivered by LUCS at term withaverage birth weight without any complication.Her postnatal period was uneventful.

Birth History

Feeding History

She was on exclusive breast feeding upto six months of age then adequate complimentary feeding was started. Now she is on family diet.

Immunization History

Immunized as per EPI schedule.

Treatment History

Before admission, she was treated with oralantibiotic, paracetamol syrup and received 1episode of blood transfusion. After admissionhere she received blood transfusion twice andgot injectible antibiotic and oral antipyretic.

Family HistoryRanjila is the second issue of non-consanguineous parent. Other family members are healthy. There is no history of similar illness in her family.

Socioeconomic HistoryShe belongs to a poor socioeconomic status, lives in a tin-shed house, uses sanitary latrine and drinks tube-well water.

General Examination

• Appearance - Ill-looking, toxic• Anaemia - Moderately pale• Jaundice -• Cyanosis -• Clubbing - Absent• Koilonychia -• Oedema -• Dehydration -• Bony tenderness - Present

General Examination contd.

• Lymph-node - Generalized lymphadenopathy involvinganterior and posterior cervical chains, Submandibularregion of both sides. Largest one measuring about 1.5cm X 1 cm located at left anterior cervical chain. Lymphnodes having smooth surface, firm consistency, mobile,free from underlying structure and overlying skinwithout any discharging sinus.

• Skin - BCG mark present. No bleeding manifestation

• Eye - Normal. No proptosis.

• Ear, nose, throat - Normal

• Signs of meningeal irritation - Absent

Vital Signs

• RR 36/min.

• Pulse 120/min.

• Temp. 1020F

• BP 95/60 mm of Hg

Anthropometry

• Height 94 cm

• Weight 12 kg

• WHZ - 1.5 SD

• HAZ 0.8 SD

Systemic Examination

• Mouth and Fauces No gum hypertrophy, no mucosal petechie or purpura

• Anemia Moderately pale

• Jaundice Absent

• Lymph nodes Stated earlier

• Skin No bleeding manifestation

• Bony tenderness Present

Hemopoitic System

• Liver Palpable. 5 cm from right costal margin along right mid clavicular line, non tender, firm in consistency, having sharp border and smooth surface. Upper border of liver dullness in right 5th inter costal space.

• Spleen Palpable , about 3 cm along its long axis, non tender, firm, smooth surface.

Hemopoitic System contd.

Examination of Other systems revealed normal findings.

Salient Features

Ranjila, a 2 years 6 months old female childpresented with high grade continuous fever andprogressive pallor for 1 month. She had nohistory of vomiting, convulsion or visiting anyendemic zone of Kala-azar. She was ill-looking,toxic, febrile, moderately pale, bony tendernesspresent, no gum hypertrophy or proptosis. Therewas generalized lymphadenopathy withhepatosplenomegaly without ascites. Othersystemic examination revealed normal findings.

Provisional Diagnosis

Acute Leukemia (most probably acute lymphoblastic leukemia)

Differential Diagnosis

1. Acute Myeloid Leukemia

2. Kala-Azar

Investigations

To establish Diagnosis:

CBCHb 7.1 gm/dLTotal Count of WBC 7800/cu mmDifferential WBC Count

Neutrophil 10%Lymphocytes 66%Monocyte 04%Atypical Cells 20%

Platelet Count 37,000/cumm

Investigation

Peripheral Blood Film

RBC - Anisochromia with anisocytosis

WBC - Atypical Cells are seen

Platelet - Reduced

Investigation

Bone Marrow study

Cellularity

Myeloid Erythroid Ratio

Erythropoisis

Granulopoisis

Megakaryopoisis

Investigations

For Assessment and Management Purpose:• Serum Uric Acid• Serum Electrolytes• Serum Calcium• Serum Phosphate• SGPT• Blood Urea• Serum Creatinine• Chest X ray • Urine for R/M/E• Urine C/S• Blood C/S

Final Diagnosis

Acute Lymphoblastic Leukemia (FAB type )

Management

CounselingAbout the nature of diseaseDisease Course Treatment optionTreatment available in our countryTreatment cost Duration of treatmentComplication of disease and treatmentOutcomeFollow up

Management

Supportive

• Neutropenic diet

• Hydration with IV fluid 1500mL/day (3L/m2

Body surface area/day)

• Antipyretic (paracetamol- 1 and ½ tsf SOS)

• Antibiotic (Inj. Ceftriaxone 1gm IV once daily)

• Packed cell transfusion 10ml/kg

Risk based multi-staged protocolizedpolychemotherapy

1. Induction of remission

2. Consolidation /CNS phase

3. Interim Maintenance Phase

4. Delayed Intensification phase

5. Maintenance

Induction of remission: (1-5 weeks) Inj. Vincristine

Inj. L - asperginaseTIT (Hydrocortisone + MTX + Cytarabin) Tab DexamethasoneTab CotrimoxazolTab 6 -Mercaptopurine

Consolidation: TIT (Hydrocortisone + MTX + Cytarabin) (6-8 weeks) Tab 6- Mercaptopurine

Tab Cotrimoxazol

Interim maintenance phase : Inj. Vincristine, (9-16 weeks) Tab. 6- MP

TITTab MTXTab Cotrimoxazole

Delayed intensification phase : TITPart I (17-20 weeks) Inj. Vincristine,

Inj. Daunorubicin,Inj. L - asperginaseTab DexaTab CotrimoxazoleTab 6 -Mercaptopurine

Delayed intensification phase :

Part II (21-23 weeks) TIT

Inj. Cyclophosphamide

Inj. Cytarabine,

Tab 6 -Mercaptopurine

Maintenance : (21/2yrs)

Daily: Tab 6- MercaptopurineWeekly: Tab MTX

Tab CotrimoxazoleMonthly: Inj Vincristin

Tab DexamethasoneEvery 3 mothly:

TIT (Hydrocortisone + MTX + Cytarabin)