Clinical meeting

1. Welcome
to
Clinical Meeting
Dr. Maimuna Sayeed
Resident, Phase-A
Paediatric Gastroenterology & Nutrition
BSMMU

2. Particulars of the Patient
Name: Md. Huzaifa
Age: 6 years
Sex: Male
Address: Gazipur
Date of admission: 29/10/2016
Date of examination: 30/10/2016
Informant: Mother

3. Presenting Complaints
1. Fever for 2 months
2. Multiple nodular swelling in different parts of
body for 2 months
3. Swelling of left testis for 2 months
4. Gradual pallor for 1 month
5. Swelling of right eye for 7 days

4. History of Present Illness
According to the statement of the informant
mother, her child was reasonably well 2 months
back. Then he developed fever, which was initially
low grade, then became high grade, continued in
nature, not associated with chills and rigor.
Highest recorded temperature was 104°F and
fever was not subsided by taking oral antibiotics.
Mother noticed multiple nodular painless swelling
in both side of neck and groin for same duration.
At the same time he also developed painless
swelling of left testis.

5. History of Present Illness (contd.)
Mother also noticed progressive pallor for last one
month. She also mentioned about gradual swelling
of his right eye for 7 days.
There was no history of headache, convulsion,
blurring of vision, cough, respiratory distress, gum
swelling, bleeding manifestations, weight loss,
exposure to ionizing radiation or contact with
known TB patient.

6. History of Present Illness (contd.)
He was treated by different physician with oral
antibiotics. Later he got admitted to Dhaka Shishu
Hospital and had 4 units of blood transfusion. Due
to financial constrains they took discharge from
there. Then after one week he got admitted into
BSMMU for further evaluation and management.

7. Birth History
He was delivered by LUCS at term in a private
hospital with average birth weight without any
complications. His antenatal, natal and post-
natal period was uneventful.
Developmental History
He is developmentally age-appropriate.
History of past illness
Nothing significant.

8. Feeding History
He was on exclusive breast feeding until his 6
months of age. Then complimentary feeding was
started. Now he is on family diet.
Immunization History
He is immunized as per EPI schedule.
Family History
He is the 2nd issues of non-consanguineous
parents. No other family member has similar
types of illness.

9. Socio-economic History
He belongs to a middle class family . His father is a
businessman and mother is a housewife. Their
average monthly income is around 20,000 tk.
Treatment History
He took oral antibiotics & syrup paracetamol during
this period of illness. He also received blood
transfusion 4 times.

10. Physical Examination

11. General Examination
Appearance: Ill-looking, swelling of right eye
Moderately pale
Jaundice: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Edema: Absent
Dehydration: Absent
Skin Survey: BCG mark present, there is no
bleeding manifestations.

12. General Examination (contd.)
Lymphadenopathy:
oSubmandibular
oAnterior and posterior cervical
chain (both side)
oAxillary lymph nodes(both side)
oInguinal lymph nodes(both
side)
Size: 2cm × 2cm (Submandibular)
Discrete
Non-tender
Firm in consistency
Not fixed with underlying
structure & overlying skin
No discharging sinus

13. General Examination (contd.)
Bony Tenderness: Absent
Signs of Meningeal Irritation:
Absent
Examination of Eye: Proptosis
of both eyes (right>left)
Examination of Ear, Nose and
Throat: Normal

14. General Examination (contd.)
Vital Signs
• Temperature : 98°F
• Pulse: 96 beats/min
• Resp. Rate: 28 breaths/min
• Blood Pressure: 90/60 mm Hg (SBP lies below 50th
percentile & DBP lies between 50th - 90th percentile)

15. Anthropometry
• Weight: 17kg
(lies between 5th and 10th
percentile)

16. Anthropometry
• Height: 117 cm
(lies on 50th-75th percentile)

17. Systemic Examination

18. Haemopoietic System
Moderately pale
Bony Tenderness: Absent
Skin survey: Normal.
Oral Cavity: Healthy, no gum hypertrophy, no sign of
bleeding manifestation.
Lymph node: Submandibular, bilateral anterior and
posterior cervical lymph nodes of both sides are
palpable & largest one measuring about 2cm × 2cm in
size and all are discrete, non-tender, firm in consistency,
not fixed with underlying structure & overlying skin &
there is no discharging sinus.

19. Haemopoietic System (contd.)
Liver:
Palpable 6 cm from the right costal margin along the
midclavicular line
Surface - smooth
Consistency - firm
Margin - sharp
Non-tender
Upper border of liver dullness lies on the right 5th ICS.

20. Haemopoietic System (contd.)
Spleen:
Enlarged 8 cm from the left costal margin along it’s long axis
Surface - smooth
Consistency - firm
Non-tender
Splenic notch - present
Finger insinuation test - negative

21. Alimentary System
Oral Cavity:
Healthy
No gum hypertrophy
No bleeding manifestations.
Abdomen proper:
Inspection:
Size & shape: normal
Umbilicus: Centrally Placed , inverted
No visible mass, no scar mark.

22. Alimentary System (contd.)
Palpation:
Superficial palpation:
Abdomen is soft, non-tender.
Deep Palpation:
Liver: Enlarged 6 cm from the right costal margin .
surface smooth, Non tender.
Spleen: Enlarged 8 cm from the left costal margin
along it’s long axis.

23. Alimentary System (contd.)
Percussion:
Percussion note: Tympanic
Shifting Dullness : Absent.
Auscultation:
Bowel sound : Present

24. Genitourinary System:
Kidneys: Not ballotable
Urinary Bladder: Not palpable
Hernial Orifice: Intact
Genitalia: Male type
Testes:
size: left sided testicular
swelling was present
temperature: not raised
tenderness: absent
consistency: firm to hard
surface: smooth, not attached
to skin

25. Respiratory System Examination
 Inspection:
Respiratory Rate: 28 breaths/min
Shape of the chest: Normal
Chest Movement: Symmetrical
 Palpation:
Trachea: Centrally Placed
Chest Expansibility: Symmetrical
 Percussion:
Percussion Note: Resonant all over the chest.
 Auscultation:
Breath Sound: Vesicular
No Added sound

26. Cardiovascular system Examination
Inspection:
No visible pulsation.
Palpation:
Apex Beat: Located in the Left 5th ICS , just medial to
the midclavicular Line.
Thrill : Absent
Left Parasternal Heave: Absent.
Palpable P2 : Absent
Auscultation:
Heart Sound: 1st and 2nd heart sounds are audible in
all the four areas.
Murmur : Absent

27. Nervous System Examination
Higher Psychic Function:
Appearance : Ill-looking.
Examination of motor system:
Bulk of the Muscle: Normal
Tone of the Muscle: Normal
Power of the Muscle: Normal
Superficial Reflexes: Intact
Deep Reflexes : Intact
Examination of the Sensory system:
Intact
Examination of cranial nerves:
Intact

28. Locomotor System Examination
LOOK:
No sign of arthritis, no visible deformity,
No muscle wasting.
FEEL:
Local temperature- Not raised
Tenderness- Absent.
MOVE:
Not restricted.

29. Salient Feature
Md. Huzaifa, 6 years old boy, 2nd issues of non-
consanguineous parents, got admitted with the complaints of
fever for 2 months, which was initially low grade, then
became high grade, continued in nature, not associated with
chills and rigor, not responding to antibiotics. He developed
multiple nodular painless swelling in both side of neck and
groin region and left sided painless testicular swelling for
same duration. He also developed progressive pallor for last
1 month and swelling of right eye for 7 days.

30. Salient Feature (contd.)
There was no history of headache, convulsion, blurring of
vision, cough, respiratory distress, gum swelling, bleeding
manifestations, exposure to ionizing radiation or contact
with any known TB patient.
He was treated with oral antibiotics and got 4 units of blood
transfusion.

31. Salient Feature (contd.)
On general examination, the patient was ill-looking,
moderately pale, afebrile, bilateral proptosis present
(right>left), bony tenderness was absent, generalized
lymphadenopathy present. Vitals were within normal limit.
Anthropometry within centile chart. On systemic
examination, patient had hepatosplenomegaly & left sided
testicular swelling. There was no bleeding manifestations,
or gum hypertrophy. Examination of other systems
revealed nothing abnormality.

32. PROVISIONAL
DIAGNOSIS
?

33. Provisional Diagnosis
Acute Leukemia (Acute Myeloid Leukemia)

34. Differential Diagnosis
Acute Lymphoblastic Leukemia

35. Acute Myeloid Leukemia
Points in Favour Points against
H/O
 Fever
 Gradual pallor
O/E
 Moderately pale in spite of
getting blood transfusion
 Generalized
Lymphadenopathy
 Hepatosplenomegaly
 Proptosis
 No bleeding manifestation
 No gum hypertrophy
 No chloroma

36. Acute Lymphoblastic Leukemia
Points in Favour Points against
H/O
 Fever
 Gradual pallor
O/E
 Moderately pale in spite of
getting blood transfusion
 Generalized
Lymphadenopathy
 Hepatosplenomegaly
 Testicular swelling
 Proptosis

37. Investigations
CBC
Hemoglobin 8.4 gm/dl
TC of WBC 117.69 x 109/L
Differential counts:
Neutrophil 05%
Lymphocyte 15%
Eosinophil 0.1%
Basophil 00%
Monocyte 00%
Blast 80%

38. Investigations (contd.)
RBC Panel
RBC count 3.12 x 10
12
/L
HCT 27.2%
MCV 87.2 fL
MCH 26.9 pg
MCHC 30.9 g/dl
RDW-CV 16%
Platelet 36 x 10
9
/L

39. Investigations (contd.)
Bone Marrow Study:
Gross Description:
Cellularity Hypercellular
Myeloid : Erythroid ratio Increased
Erythropoiesis Depressed
Granulopoiesis Depressed
Megakaryocytes Scanty
Bone Marrow Differentials:
Lymphoblast 80%
Diagnosis: Acute Lymphoblastic Leukemia (ALL-L2)

40. Investigations (contd.)
Immunophenotyping
Cd3 0.34%
Cd5 3.75%
Cd7 4.82%
Cd10 87.87%
Cd19 89.99%
Cd13 1.12%
Cd33 3.88%
Cd34 50.80%
cCd79a 90.70%
HLADR 93.25%
cMPO 1.13%
Cd117 0.11%
Comment: Acute Lymphoblastic Leukemia (B cell lineage)

41. Investigations (contd.)
S. LDH 542 U/L
S. Uric acid 3.3mg/dl
S. Calcium 8.2mg/dl
S. Inorganic PO4 5.1mg/dl
S. Electrolytes:
Sodium 140mmol/l
Potassium 4.1mmol/l
Chloride 105mmo/l
TCO2 28mmol/l

42. Investigations (contd.)
S. ALT 40U/L
Prothrombin time 14.7sec
APTT 28.2sec
S. Creatinine 0.51mg/dl
RBS 5.8 mmol/L
HBsAg Negative
Blood Grouping A+ve
CSF study Negative for malignant cell, CNS-1

43. Investigations (contd.)
Chest X-ray P/A view
Normal

44. Final Diagnosis
Acute Lymphoblastic Leukemia
(B-cell lineage) with Hyperleukocytosis

45. Treatment
Counselling.
Supportive :
Diet – Neutropenic.
Adequate hydration (2 ltr/sq.m/day) with NaHCO3
Nystatin oral drop
Chlorohexidine mouth wash
Acriflavin hip bath.
Tab. Allopurinol
Tab. Paracetamol
Syp. Antacid

46. Treatment (contd.)
 Specific Treatment
Protocol based Multiagent Chemotherapy (UK ALL 2003 -
Regimen B)

47. 30.10.16 02.11.16
CBC
Hemoglobin 7.9 gm/dl
TC of WBC 122.00 x 109/L
Differential counts:
Neutrophil 10%
Lymphocyte 10%
Eosinophil 0.1%
Basophil 00%
Monocyte 00%
Blast 80%
Platelet <10 x 109
/L
CBC
Hemoglobin 11.1 gm/dl
TC of WBC 84.72 x 109/L
Differential counts:
Neutrophil 10%
Lymphocyte 10%
Eosinophil 0.1%
Basophil 00%
Monocyte 00%
Blast 80%
Platelet <10 x 109
/L

48. Follow up on 03/11/16 (day-6)
Subjective Objective Assessment Plan
No new
complaints
•Ill looking
•mildly pale
•Proptosis (right>left)
•Oral cavity: Healthy
•Pulse: 88 b/m
•BP: 80/60 mmHg
•RR: 24/min
•Temp: 98○
F
• G. Lymphadenopathy
•Liver: 5cm palpable
•Spleen: 7cm palpable
•Testicular swelling
(left)
•Bowel : Moved
•U/O: 3ml/kg/hr
Static Start of
chemotherapy

49. Follow up on 07/11/16 (day-10)
Subjective Objective Assessment Plan
No new
complaints
(IR D3)
•Ill looking
•mildly pale
•Proptosis (right)
•Oral cavity: Healthy
•Pulse: 82 b/m
•BP: 80/50 mmHg
•RR: 20/min
•Temp: 98○
F
• G. Lymphadenopathy
•Liver: 4cm palpable
•Spleen: 6cm palpable
•Testicular swelling
(left)
•Bowel : Moved
•U/O: 3.4ml/kg/hr
Improving  Continue
Chemotherapy
 Repeat CBC &
biochemical
work up

50. T H A N K
Y O U