SITUATIONAL PROBLEM K000119

1. Acute leukemia, debut. Hepatosplenomegaly. Anemia of moderate severity. thrombocytopenia. hemorrhagic syndrome.

2. The diagnosis of “acute leukemia” was made on the basis of clinical data: hepatosplenomegaly, hemorrhagic, anemic syndromes, intoxication. The main diagnostic criteria are laboratory data: in the general blood test – leukocytosis (less often leukopenia), the presence of blast cells, a symptom of a leukemic “failure”, anemia (hemoglobin – 78 g / l corresponds to moderate severity) and thrombocytopenia.

3. The main studies to clarify the diagnosis are:

complete blood count (leukocytosis, the presence of blasts, leukemic “failure”, anemia, thrombocytopenia);

sternal puncture (20% or more blast cells in myelogram);

cytochemical study and immunophenotyping of blasts (determination of the variant of leukemia), cytogenetic study of the bone marrow (determination of prognostically favorable and / or unfavorable cytogenetic defects);

diagnostic lumbar puncture (to rule out neuroleukemia);

Ultrasound of the internal organs (in order to clarify the degree of leukemic infiltration of the liver and spleen).

4. To verify the diagnosis and treatment, hospitalization in the hematology department is indicated. Treatment includes cytostatic therapy: polychemotherapy is used according to standard programs, depending on the type of leukemia. The stages of treatment include: induction of remission, consolidation, maintenance therapy, prevention of neuroleukemia. In acute lymphoblastic leukemia, an 8-week Holzer program is used, in acute myeloid leukemia, therapy according to the “7 + 3” protocol. The following drugs are used: Prednisolone, Vincristine, Rubomycin, Cytosar, Cyclophosphamide, 6-Mercaptopurine, Asparaginase, Etoposide. Accompanying therapy: to improve kidney function, reduce the degree of hyperuricemia – Allopurinol, antiemetic therapy, hemostatic therapy (transfusion of thromboconcentrates), replacement transfusions of erythrocyte-containing media. With a poor prognostic index in the remission phase of the disease, allogeneic bone marrow transplantation is indicated.

5. Complications of acute leukemia include bleeding of various localization; ulcerative-necrotic lesions of the mucous membranes of the gastrointestinal tract; infectious lesions; damage to the nervous system (specific infiltration of the central nervous system, hemorrhages). Side effects of cytostatic drugs include myelotoxic agranulocytosis (with a high risk of infectious complications), dyspeptic disorders (nausea, vomiting), damage to the epithelium of the mucous membranes (mucositis, enteropathy), alopecia.

CASE STUDY 70 [K000120]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

A 61-year-old woman complains about the presence of painless tumor-like elastic formations on the lateral surface of the neck and in the axillary areas, as well as heaviness in the left hypochondrium during fast walking, and increased sweating at the appointment of a local general practitioner in a polyclinic. The above complaints appeared about a year ago, gradually increased.

Objectively: the general condition is satisfactory. Skin and visible mucous membranes of normal color. Palpated conglomerates of enlarged submandibular, cervical, axillary, inguinal lymph nodes, palpation – elastic, painless, inactive, the skin over them is not changed, symmetrically enlarged – cervical and submandibular up to 2-3 cm, axillary up to 3-4 cm, inguinal up to 4 cm in diameter. Vesicular breathing in the lungs, wheezing is not audible, NPV – 18 per minute. Heart sounds are clear, heart rate is 78 beats per minute. BP – 120/80 mm Hg. Art. The abdomen is soft and painless. The edge of the liver does not protrude from under the edge of the costal arch. The spleen protrudes 2 cm from under the edge of the costal arch, the edge is elastic, painless.

Complete blood count: erythrocytes – 3.6 × 1012, Hb – 129 g / l, platelets – 200 × 109 / l, leukocytes – 39 × 109 / l, stab neutrophils – 2%, segmented neutrophils

– 2%, lymphocytes – 92%, monocytes – 4%, ESR – 30 mm/h, Botkin-Gumprecht shadows – 1-2 in the field of view.

Questions:

1. What is the preliminary diagnosis?

2. Justify your diagnosis.

3. What examinations should be prescribed to clarify the diagnosis?

4. Select and justify the tactics of patient management.

5. What is the prognosis for this disease, and what complications are possible?

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