BMS 561, Hematology Fall 2016    Case studies

The following case studies are not actual patients. They combine elements from different cases to emphasize important aspects

Case 1 

HISTORY:  Patient Presentation

A four-year-old African American male diagnosed with sickle cell disease in the newborn period was admitted to the hospital with abdominal pain. Two days prior to admission, he was seen in the emergency room for abdominal pain and sent out on pain medicine.

PHYSICAL EXAM

Height	100 cm (25th percentile on growth chart)
Weight	15 kg (25th percentile on growth chart)
Temperature:	38.9ºC
Heart Rate:	135
Respiratory Rate:	40
Blood Pressure	100/60 mmHg
Oxygen Saturation Level:	87% (normal range: 92%-98%)

 

HEENT:	Normocephalic, pupils reactive, tympanic membranes clear, oropharynx clear
Neck:	No adenopathy
Chest:	Mild subcostal retractions. Audible rales at lung bases.
Heart:	Tachycardic with III/VI murmur
Abdomen:	Mild distension, diffusely tender to palpation
Genitourinary:	Circumcised male, no priapism
Extremities:	Warm
Neurologic:	Crying, alert boy. Face was symmetric. Moved all extremities.

 

 

 

 

 

LABORATORY DATA

	Patient Value	Normal Value
WBC	15,000	4,000-12,000/?L
HGB	6.3	11.5-13.5 g/dL
HCT	18	34%-40%
PLT	560,000	140,000-440,000/?L
MCV	89.0	75-87 fl
Retic %	14%	0.5%-1.5%
Rectic Absolute	0.2125	0.024-0.084 M/?L

 

1  What history, including symptoms, would be most helpful in evaluating this patient?

2  What does a prior history of abdominal pain reflect? What does Bone pain and swollen, painful fingers (dactylitis) reflect in this disease?

3  He had a temperature of 101 degrees Fahrenheit yesterday.what does that indicate?

4  He has been coughing 2-3 times a day and intermittently through the night.what does that indicate??

5  Does family history indicate sickle disease?

6  What additional physical findings might occur in patients with sickle cell disease?  Discuss Jaundice and Splenomagaly??

7   What other labs would you request?  Compare the lab findings with normal ranges

Discuss Peripheral smear, hemoglobin electrophoresis,

Blood culture; Blood Type and screen for antibodies
LDH; Haptoglobin levels

Amylase and Lipase

8  Discuss MCV, MCH, RDW, ESR, Hematocrit and  red cell morphology in this disease

9  What was your differential diagnosis when you first saw the patient? Discuss the following in diagnosing the disease

Cholecystitis;  Pneumonia;  Upper respiratory tract infection;  Vaso-occlusive pain crisis

10 what are the differences between sickle cell disease, HbC, HbE  and Thalassemia diseases?

11  Discuss Iron deficiency anemia, thalassemia syndromes and sickle cell anemia

12   How would you treat this patient?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 2

On review of symptoms, The patient reports difficulty concentrating, fatigue, feeling faint when she stands quickly, and vague gastrointestinal discomfort with some decrease in appetite.

She denies any history of previous trauma, diplopia, dysphagia, vertigo, vision loss, loss of consciousness, back pain, or symptoms of bowel or bladder dysfunction.

Her family history is negative for neurologic, psychiatric, and autoimmune diseases. Her medications include an antihypertensive as well as an occasional anti-inflammatory drug for episodic headache. Social history reveals a single woman who smokes about one-half pack of cigarettes per day, drinks alcohol only socially, and denies illicit drug use. She has a high school education and, until recently, has worked in the office of a trucking company.

Physical Examination

Pale 65 y.o. WF who appears well-nourished, alert, and oriented.

Summary of Physical Examination
Vital Signs	T-98.6, HR-76, R-18, B/P-130/80 supine and 95/52 upon standing
Height/Weight	5’4?/120 lbs.
Head	Normocephalic; oropharynx clear but pale; palpebral conjunctivae pale
Neck	Supple, full active and passive ROM without pain, without audible bruits; no lymphadenopathy; no thyromegaly
Back	No spine tenderness
Lungs	Clear to auscultation
Heart	Regular rate and rhythm; no murmurs
Abdomen	Soft, nontender; no organomegaly
Rectal	Normal rectal tone; no fissures
Extremities	No clubbing, cyanosis, or edema; FROM
Skin	Pale; no rash

The general physical exam is unremarkable except for orthostatic hypotension and weight loss of 3 pounds since her last visit 6 months ago. She is alert and oriented times three. Her Mini-Mental Status Exam score is 26 out of 30. She misses one point on serial 7s and is able to recall three of three items. There is evidence of bilateral mildly diminished vibration and proprioception. Her reflexes are 3+/4+ throughout with negative Babinski reflex.

Laboratory Studies

You order routine laboratory studies, which include complete blood count (CBC) with smear and chemistry screen. In addition, you order a serum vitamin B₁₂ level to investigate further the etiology of her fatigue and pale mucosa. Results from the CBC and smear reveal a borderline macrocytic anemia. The chemistry panel is within normal limits. The serum vitamin B₁₂ level you requested is 215 picograms per milliliter (pg/mL). This level is considered within a “normal range” by some laboratories, but you take into account her other signs and symptoms and request confirmatory testing with methylmalonic acid (MMA) and homocysteine (Hcy) levels.

Results of Confirmatory Testing

Both MMA and Hcy levels are elevated. Her MMA is greater than 0.5 micromoles per liter (?mol/L), and her Hcy is greater than 17 ?mol/L, confirming your suspicion.

you order an anti-intrinsic factor (IF) antibody test

 

Answer all the questions with details:

1          Based on the case history and lab data what is your diagnosis?

2          Do any of the presenting complaints raise your index of suspicion about a possible B₁₂ deficiency?

3          Do you think that the risk factors this woman appear to have for a vitamin B₁₂ deficiency?

4          Are there any aspects of her physical examination that suggest a vitamin B12 deficiency?

5          outline differential diagnosis and indicate how you proceed with the treatment?

 

 

 

Case 3

HISTORY

Patient Presentation

A 17-month-old male is admitted to the hospital with a two-week history of fever (T max 104° F) and a two-day history of rash on his legs. Ten days ago, his primary care physician treated him with a 7 day course of Ceftin for a presumptive diagnosis of otitis media. Upon follow-up visit, it was found that he was still febrile and required ibuprofen nearly daily to control fevers. It was also found that he had lost weight, presumed to be due to decreased appetite.

PHYSICAL EXAM

Height, Weight

Height: 83 cm (75th percentile)

Weight: 10 kg (10th percentile)

Vitals

• Temperature 36.8 (axillary)

Normal range (36.0-36.9)

• Heart rate: 152

Normal range (80-130)

• Resp. rate: 48

Normal range (20-30)

• BP128/59

Normal range (100-129/50-59)

Neck

Snotty lymph node enlargement diffusely through both anterior cervical chains.

SKIN

Pale, scattered red-purple spots ranging in size from 1-3 mm and non-blanching, located over legs,back, arms and trunk

 

LABORATORY DATA

The results from the CBC on admission are as follows:

 

Test                                         [Patient Result                                    Normal Range

 

 

Hemoglobin                            8.9g/dl                                     10.3-14.9 g/dL

 

Hematocrit                              26.9%                                      33-44%

 

MCV                                       86.8Fl                                      73-91Fl

 

MCH                                       29.7Pg                                     29.5-36Pg

 

MCHC                                                33.1g/dL                                 29-36g/dL

 

RDW                                       15.8%                                      12-14%

 

WBC                                       5,200ul                                    4,800ul – 10,800ul

 

Platelets                                   12,000/ul                                 150-400,000/uL

 

CLINICAL COURSE

The patient was started on combination chemotherapy consisting of Prednisone, Vincristine, and L-asparaginase  (induction phase).

 

What is your diagnosis?

What tests are needed to diagnose the disease?

Surface markers?

Chromosomal abnormalities

Specific staining

TdT?

Discuss Differential diagnosis