Dr. Shukur Ullah presented the case of 6-year old Tabassum who presented with 1 month of high grade intermittent fever, 20 days of progressive pallor, and one episode of hematemesis. On examination, she was ill-looking and moderately pale with bony tenderness, lymphadenopathy, and hepatosplenomegaly. Investigations revealed pancytopenia, blasts in the peripheral blood, and a hypercellular bone marrow with >90% lymphoblasts. She was diagnosed with acute lymphoblastic leukemia (ALL). Her management involved counseling, supportive care, and risk-based multi-staged polychemotherapy consisting of induction, consolidation, interim maintenance, delayed
2. Particulars of the patient
Name : Tabassum
Age : 6 Years
Sex : Female
Address : Narayanganj
Date of admission : 05/07/17
Date of examination : 07/07/17
Informant : Mother
4. History of present illness
According to the statement of mother,
Tabassum was well 1 month back. Then she
developed fever which was high grade,
intermittent in nature without chills and rigor.
Mother also noticed that her child was
getting progressively pale associated with
fatigability and weakness for last 20 days.
5. History of present illness
She had also history of blood mixed vomiting
once 2days back containing undigested food
particles. She had no history of cough,
respiratory distress, headache, convulsion,
taking any offending drug or blood
transfusion.
6. History of present illness
With these problems she was treated by
several physicians. As the condition was not
improving, she got referred to Dhaka Shishu
Hospital for further evaluation and
management. After admission she received
blood transfusion 3 times and got some
injectable and oral medications.
7. History of past illness
There was no significant past illness.
Birth history
Tabassum was delivered normally at term
with average birth weight without any
complication. Her postnatal period was also
uneventful.
8. Developmental history
Age appropriate.
Feeding history
She was on exclusive breast feeding upto
6 months of age then adequate
complementary feeding was started. Now
she is on family diet.
Immunization history
Immunized as per EPI schedule.
9. Treatment History
Before admission she was treated with oral
antibiotics and paracetamol syp. After
admission she received blood transfusion 3
times and got some injectable and oral
medications. Her last date of blood
transfusion was 07.07.2017.
10. Socio-economic history
The number of family members are 3. Her
father is a businessman. He is the only
earning person in his family and his
monthly income is 15,000 taka
(5,000 tk/person). Mother is a housewife .
Family history
Tabassum is the only issue of a non
consanguineous parents. Other family
members are healthy. There was no history
of similar illness in his family.
13. •Lymph nodes- Palpable in right and left
posterior cervical chains, both sub mental
and sub mandibular regions. Largest one
was present in the left posterior cervical
chain measuring about 3 cm x 2 cm and the
rest others were about 1 cm in diameter. All
the nodes were firm, non tender, discrete,
free from underlying structure and overlying
skin.
General examination
14. General examination
• Skin - BCG mark was present. No
bleeding manifestation.
• Eyes - Normal. No proptosis.
• Ear, nose, throat - Normal.
• Signs of meningeal irritation - Absent.
15. General examination
• Vital signs:
R/R : 32/ min
Pulse : 124/ min
Temp : 1010
F
B/P : 90 / 60 mm Hg
• Anthropometry:
Weight : 19 kg
Length : 110 cm
BMI : 15.7 kg/m2
16.
17. Systemic examination
Hemopoietic system examination
Mouth and fauces : No gum hypertrophy , no
mucosal petechie or
purpura.
Anemia : Moderately pale
Jaundice : Absent
Lymph nodes : Enlarged
Bony tenderness : Present
18. Hemopoietic system examination
Liver : Palpable, 8 cm from the right costal
margin along the midclavicular line, non
tender, firm, having sharp border and smooth
surface. Upper border of liver dullness was in
the right 5th intercostal space.
Spleen : Palpable, about 3 cm along its long
axis, non tender, firm and surface was
smooth.
20. Tabassum, a 6 years old girl presented with
high grade, intermittent fever for 1 month,
progressive pallor for 20 days and
hematemesis once. She had no history of
respiratory distress or convulsion. She was ill
looking, febrile, moderately pale. Bony
tenderness, lymphadenopathy and
hepatosplenomegaly were present. There
were no gum hypertrophy or proptosis.
Salient features
24. Investigation plan
To establish the diagnosis:
• CBC with PBF
• Bone marrow study:
Morphology
Immunophenotyping
Cytogenetics
25. For assessment and management:
• Chest X-ray
• Serum uric acid
• Serum electrolytes
• Serum calcium
• Serum phosphate
• Serum LDH
• Renal function test
• Liver function test
• CSF study
37. Counseling
Nature of disease
Disease Course
Treatment option
Treatment available in our county
Treatment cost
Duration of treatment
Complications of disease and treatment
Outcome
Follow up
38. Supportive treatment
• Isolation of the patient (Reverse)
• Neutropenic diet
• Hydration : IV fluid 2300 mL /day
(3L/m²/day)
• Antipyretic: Paracetamol
• Antibiotic : Inj. Ceftriaxone 2g I/V once
daily
• Packed cell and platelet transfusion
• Tab. Allopurinol (10mg /kg/day)
39. Risk based multi-staged polychemotherapy-
1. Induction of remission
2. Consolidation
3. Interim Maintenance Phase
4. Delayed Intensification phase
5. Maintenance
Specific treatment
40. Induction of remission:
(1-5 weeks) Inj. Vincristine
Inj. L - asperginase
TIT (MTX,
Cytarabine,Hydrocortisone)
Dexamethasone
Tab Cotrimoxazol
6-MP