Chronic Myeloid leukemia in Papua New Guinea

1. Medicine
case
Presentation
Consultants: Professor Sir Isi Kevau
Dr Amana, Dr Maino
Registrars: Dr Ken and Dr Baiwan
Dr Ona and Dr Ben
RMO: Dr Moide
Medical Students: Osito Hagayo,
Elmaritta Kemba, Anderson Perea.

2. Patient identification Data
▪ Patient initial: KS
▪ Sex/age: Male/25
▪ Origin: Pogera,Liagam District, Enga Province
▪ Place of Residence: Morata
▪ Admission Detail: Patient was admitted on the 17th April via
Emergency Department at around 7pm.
▪ Source of History: Patient
▪ Religion: Apostolic
▪ Next of Kin: Brother

3. Presenting symptoms
▪ Dizziness and fatigue 3/12

4. Background history
▪ Two years ago the patient developed the abdominal swelling from
the left upper quadrant and has progressively increase in size till
present. The swelling has caused abdominal discomfort (early
satiety, abdominal fullness)
▪ He has been visiting different hospitals (Wabag General Hospital
and Kudzip Hospital) with the above complain but no help was
given.
▪ Early this year he traveled to Port Moresby and due to worsening
symptoms he presented to ED PMGH.

5. History of presenting illness
▪ The patient has become progressively weak over the past 3/12s,
and he tires easily walking short distances and was unable to do
his normal activities.
▪ He experienced episodes of dizziness and almost fainted on
prolonged standing. This prompted relatives to bring him to the
Port Moresby General hospital.

6. Specific interrogation
▪ He denies:
▪ Pruritus
▪ Bruises
▪ Bleeding from gums
▪ Joint pain
▪ He admits:
▪ Dyspnea on exertion
▪ Night sweats.
▪ He has lost his appetite
▪ Lost a significant amount of
weight.

7. System Review
▪ Respiratory system:
▪ No cough
▪ No haemoptysis
▪ GIT:
▪ No rectal bleeding or melena
▪ No change in bowel habit
▪ No vomiting
▪ No abdominal pain
▪ No jaundice
▪ Cardiovascular system:
▪ No chest pain on exertion
▪ No palpitation
▪ No paroxysmal Nocturnal Dyspnea
▪ No orthopnea
▪ Central Nervous System:
▪ No head ache
▪ No photophobia/visual disturbances
▪ No confusion
▪ Genitourinary system
▪ No hematuria

8. Past Medical history
▪ First admission
▪ No personal History of Tuberculosis, diabetes, Hypertension,
Malaria
▪ Unaware of any drug allergy

9. Family history
▪ 1st born in a family of eight (8)
▪ All siblings alive and well
▪ No family history of Leukemia or
other bleeding disorder, TB, Diabetes,
Hypertension or other malignancy.

10. Social History
▪ Not married
▪ He did not attend school
▪ Subsistence farmer
▪ Currently living at Morata
Settlement
▪ Habits
▪ Chew betelnut and drink beer
occasionally
▪ Does not smoke

11. Examination
General Observation
▪ Melanesian male sitting up in
bed, not in any respiratory
distress
▪ Pale
▪ Wasted
▪ Distended abdomen
Vitals
▪ BP:100/60 mmHg
▪ PR: 110 beats/minute RTA
bounding in nature
▪ RR: 24 breaths/minute
▪ Temperature: 37.5
▪ Weight: 40Kg
▪ Height:150cm
▪ BMI: 16kg/m2

12. Hematopoietic system examination
▪ Inspection:
▪ Hands
▪ Palmar Pallor
▪ No koilonychia
▪ Face
▪ Conjunctival pallor
▪ Soft palate pallor
▪ No gum hypertrophy/haemorrhage
▪ No angular stomatitis
▪ Skin
▪ No petechiae or ecchymosis,
▪ No scratch mark.
▪ No joint swelling
▪ Palpation:
▪ No palpable lymph nodes
(epitrochlear, cervical, supraclavicular,
axillary and inguinal)
▪ No bone tenderness
▪ Massive splenomegaly 30 cm from
the left coastal margin to right groin
and inguinal area.
▪ No hepatomegaly

13. Gastrointestinal examination
Inspection:
▪ Hands
▪ No peripheral stigmata of chronic liver disease
▪ Face
▪ No scleral icterus
▪ Chest
▪ No gynecomastia
▪ No scanty hair in axillar
▪ Abdomen
▪ Asymmetrical distended abdomen
Palpation:
▪ Splenomegaly 30 cm from sub coastal
margin to right groin and inguinal area
and extending to left flank
▪ No hepatomegaly
▪ No signs of ascites (no shifting dullness
or fluid thrill)

14. Respiratory system examination
▪ Inspection
▪ Hands:
▪ No Hypertrophy pulmonary
osteoarthropathy
▪ No peripheral cyanosis
▪ Face/neck:
▪ No tracheal tug
▪ Chest
▪ No use accessory breathing muscle
▪ Chest symmetrical, no deformity
▪ Palpation:
▪ Trachea midline
▪ Chest expansion equal on both side
▪ Percussion
▪ No dullness or hyper resonance to
percussion bilaterally
▪ Auscultation
▪ Air entry equal
▪ Vesicular breath sound
▪ No added sound

15. Cardiovascular system Examination
Inspection
▪ Hands
▪ No peripheral stigmata of infective
endocarditis
▪ Face/neck
▪ JVP not raised
▪ Chest
▪ No visible pulsation
Palpation
▪ Apex beat 5th LICS MCL
▪ No heaves or thrill
Auscultation
 Hyperdynamic two heart sound
 No murmur

16. Central Nervous System examination
▪ Higher function:
▪ Conscious
▪ OTPP
▪ Right handed
▪ Cranial nerves intact
▪ No signs of meningeal irritation
▪ Motor examination:
▪ Tone is normal
▪ Power is 5/5
Reflex Right Left
Finger ++ ++
Supinator ++ ++
Biceps ++ ++
Triceps ++ ++
Knee jerk ++ ++
Ankle jerk ++ ++
Plantar Normal Normal

17. Problem list
Subjective
▪ Tiredness and lethargy
▪ Dizziness and fatigue
▪ Dyspnea on exertion
▪ Abdominal swelling and
discomfort
▪ Weight loss
▪ Night sweats
▪ Early satiety
Objective
▪ Pallor
▪ Wide pulse pressure
▪ Tachycardic
▪ Wasted
▪ Asymmetrical distended
abdomen
▪ Massive splenomegaly

18. Case summary
▪ KS M/28 presents with clinical findings of myeloproliferative
disorder with associated anemia and a hyperdynamic circulation
state.

19. Provisional Diagnosis
▪ Chronic Myeloid leukemia
Differential diagnosis:
▪ Hyperreactive malarial splenomegaly.
▪ Lymphoma
▪ Myelofibrosis

20. Management
▪ Admit to ward for further investigation and management
▪ Symptomatic treatment
▪ Blood transfusion
▪ 23rd , 24th and 27th -1 unit whole blood
▪ Fefol 2 tablet ‘O’ BD
▪ Obtain medical oncologist opinion

21. Investigation
▪ Full Blood Examination
▪ Blood film
▪ Bone marrow biopsy
▪ Philadelphia chromosome (BCR/ABL)

22. Full Blood Examination
17/4/17 20/4/17 25/4/17 27/4/17 Comment
RBC 1.59 𝐱 𝟏𝟎 𝟔
/uL 1.72 𝐱 𝟏𝟎 𝟔
/uL 1.93 𝐱 𝟏𝟎 𝟔
/uL 2.23 𝐱 𝟏𝟎 𝟔
/uL
HCT 14.8% 18.1 % 17.9 % 19.6 %
Hb: 5 g/dL 5.1 g/dL 5.7 g/dL 6.4 g/dL Normochromic
normocytic anemia
MCV 93.1 fL 107 fL 92.2 fL 87 fL
MCH 31.4 pg 29.7 pg 29.5 pg 28 pg
MCHC 33.8 g/dL 27.7 g/dL 32 g/dL 32 g/dL
WCC 432.18 𝐱 𝟏𝟎 𝟑
/uL 398.98 𝐱 𝟏𝟎 𝟑
/uL 367.09 𝐱 𝟏𝟎 𝟑
/uL 361.26 𝐱 𝟏𝟎 𝟑
/uL Leukocytosis
Neutrophil 348.1 𝐱 𝟏𝟎 𝟑
/uL 316.4 𝐱 𝟏𝟎 𝟑
/uL 290 𝐱 𝟏𝟎 𝟑
/uL 283 𝐱 𝟏𝟎 𝟑
/uL Neutrophilia
Lymphocyte 23.4 x 103
/uL 42.7 x 103
/uL 32 x 103
/uL 30.2
Monocyte 37.4 x 103
/uL 19.8 x 103
/uL 25 x 103
/uL 21 x 103
/uL
Eosinophil 13.9 x 103
/uL 13.1 x 103
/uL 3 x 103
/uL 5 x 103
/uL
Basophil 2.2 x 103
/uL 7.1 x 103
/uL 14 x 103
/uL 20 x 103
/uL
Platelet 80 𝐱 𝟏𝟎 𝟑
/uL 94 𝐱 𝟏𝟎 𝟑
/uL 138 𝐱 𝟏𝟎 𝟑
/uL 144 𝐱 𝟏𝟎 𝟑
/uL Thrombocytopenia

23. Biochemistry
Test Result
Liver Function Test
• Total protein
• Albumin
• AST
• ALT
• ALKP
• GGT
• Total Bilirubin
• 65
• 32
• 6
• 6
• 92
• 33
BUN 3.5
Serum electrolytes
• Potassium
• Sodium
4.9
138
Creatinine 102
Chloride 102

24. Peripheral blood film result -25/4/2017
▪ Markedly elevated dysplastic granulocytes with prominent
eosinophilia.
Features are suggestive of CML in chronic phase.
▪ For Bone marrow Biopsy and Philadelphia study.

25. Progress note
▪ Patient was transferred to oncology unit as a case of CML for
further treatment.

26. ▪ Thankyou