Bumps on neck and groin of a 2 year
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Bumps on neck and groin of a 2 year

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Bumps on neck and groin of a 2 year Bumps on neck and groin of a 2 year Presentation Transcript

  • CASE STUDY BUMPS ON THE NECK AND GROIN OF A 2-YEAR OLD MALE PRESENTED BY ANNE SAHITHI S.T VISHAKHA KUMAR 4/8/2014 1
  • 4/8/2014 2 PATIENT:- 2-year old boy. CHIEF COMPLAINT:- Bumps on neck and groin
  • 4/8/2014 3 HISTORY OF THE PATIENT  1- to 2-week of bumps on his neck and groin.  blood test revealed a high white blood cell (WBC) count and a low platelet count. The parents of the patient say that he had bilateral knee pain and cough for the past week.  The PCP had mentioned the bumps on his neck and his cough
  • 4/8/2014 4 MEDICAL & FAMILY HISTORY The patient’s immunizations are up to date.  He had seasonal allergies, with symptoms that include itchy eyes and runny nose.  His recurrent ear infections have been resolved by pressure-equalization tubes and adenoidectomy. The patient’s maternal grandmother and maternal uncle have long history of QT syndrome. o His paternal great-grandfather has a low platelet count. The patient lives with his parents.  His mother is currently at 31 weeks’ gestation, originally with triplets but currently with twins (one fetus recently died in the uterus).
  • 4/8/2014 5 PHYSICAL EXAMINATON: Symptoms and abnormalities were found in the: 1. respiratory system, 2.Lymphatic and musculoskeletal systems. 3. cough, leg and knee pain 4. he also had swollen lymph glands
  • 4/8/2014 6 CLINICAL & LABORATORY FINDINGS • Initial complete blood count (CBC) testing were marked leukocytosis and thrombocytopenia. •The patient’s chemistry findings include increased glucose and lactate dehydrogenase (LDH) levels, as well as decreased blood urea nitrogen (BUN), creatinine, and osmolality. • The abnormal elevated WBC count caused an automatic manual review of the patient’s blood smear. •The decreased BUN and creatinine levels indicated that further testing was required.
  • 4/8/2014 7 Elevated LDH levels are an indicator for acute or chronic tissue damage and can be used to monitor the progression of certain cancers.
  • 4/8/2014 8 Peripheral blood smear (PBS) • Thrombocytopenia combined with leukocytosis was observed. The differential showed a marked decrease in: 1.neutrophils, 2.lymphocytes, and 3.monocytes. •Decreased relative WBC count, polychromasia and schistocytes. • The most striking characteristic of the patient’s PBS is a predominance (ie, 74%) of blasts. • The high blast percentage falsely elevated the WBC count in the initial CBC. • The most striking characteristic of the bone marrow (BM) differential was hypercellularity, with a blast result of 94%.
  • 4/8/2014 9 A, image illustrating leukocytosis, thrombocytopenia, and lymphoblast. B, Bone marrow image illustrating hypercellularity and increased proliferation of lymphoblast.
  • 4/8/2014 10 DIAGNOSIS & RESULTS The patient’s diagnosis at this point without the results of further testing would be acute leukemia. Flow cytometry testing indicates that the side scatter plot versus marker CD45, a common leukocyte antigen, showed an abnormal population of immature cells in the R2 blast gate, which accounted for 40% of the nucleated cells studied Results of flow cytometry testing indicating an abnormal population of leukocytes in the R2 blast gate. PerCP, peridinin chlorophyll; FSC, forward scatter. These blast cells were then further differentiated; it was noted that the B cells were positive for markers CD19, CD22, CD10, and TdT. These cells also tested positive for human leukocyte antigen serotype DR (HLA-DR)
  • 4/8/2014 11 The test results indicate that the patient’s acute leukemia was subtyped to pre–B-cell acute lymphoblastic leukemia (Pre-B ALL). A fluorescence in situ hybridization (FISH) panel was performed; the results indicated no TEL/AML1, BCR/ABL, or MLLgene arrangement. It was also noted that no trisomies were observed on chromosomes 4, 10, or 17. Patients often experience fever, bleeding, fatigue, and severe bone pain. Bone pain can be a possible result of tumor infiltration or marrow necrosis. Patients may have nodal and extranodal involvement. Laboratory findings include a form of cytopenia, such as anemia or thrombocytopenia. The overall leukocyte count can be increased, decreased, or normal, with a median count of approximately 10 to 12 × 109/L
  • 4/8/2014 12 Flow cytometry testing can help differentiate among the various forms of B-ALL by identifying the CD markers that exist on the leukocytes. For a patient to be diagnosed with B-ALL, most of the leukocytes must express specific markers, including CD19 and/or CD20, which are primarily found on cells committed to the B-cell maturation process. Precursor-B lymphoblasts often present are TdT+ & HLA-DR+. Moreover, the expression of CD10, the common ALL antigen (CALLA), differentiates intermediate pre-B from pro-B-ALL.
  • 4/8/2014 13 TREATMENT • Includes systemic chemotherapy and CNS therapy. A number of new treatments are available to newly diagnosed patients through Children’s Oncology Group (COG) • The specific therapy recommended for patients is dependent on the risk group to which the patient belongs, according to the patient’s genetic features. Chemotherapy for ALL is divided into 3 stages.  first stage, induction therapy, to eradicate the leukemic blast population. The drugs administered during this period are usually a glucocorticoid, vincristine, and asparaginase.  second stage, the CNS prophylactic stage, is administered because the most common site of relapse is the CNS. The drugs in this stage are administered at higher doses. Periodically, high-dose methotrexate (an antimetabolite) and 6-mercaptopurine (an immunosuppressant) can be used.  final stage of treatment, maintenance chemotherapy, is designed to eradicate any remaining leukemic cells and to prolong remission. • To be cured, patients with pre-B ALL require a 2- to 2½-year course of therapeutic agents. It has been observed that males need to be treated longer than females because relapse can occur in the testes.
  • 4/8/2014 14
  • 4/8/2014 15 REFERENCE Swerdlow S, Campo E, Harris N, et al. eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: International Agency for Research on Cancer (IARC); 2008.
  • 4/8/2014 16