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

1. WELCOME
TO
CLINICAL MEETING
Dr. Shukur Ullah
DCH Student
Bangladesh Institute of Child Health

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

3. Presenting Complaints
•Fever for 1 month.
•Progressive pallor for 20 days.

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.

11. Tabassum

12. General examination
•Appearance -Ill looking
•Anemia - moderately pale
•Jaundice
•Cyanosis
•Clubbing Absent
•Koilonychia
•Edema
•Dehydration
•Bony tenderness - Present

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

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.

19. Other systemic examinations
revealed normal findings.

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

21. Provisional diagnosis
Acute Leukemia most probably Acute
Lymphoblastic Leukemia

22. Differential diagnosis
• Acute Myeloid leukemia
• Non-Hodgkin Lymphoma

23. Investigations

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

26. Infection screening
• CRP
• Blood C/S
• Urine R/E and C/S

27. 1. CBC (on admission)
Hb : 4 gm/dl
MCV : 89.0 fl
MCH : 26.5 pg
MCHC: 32.5 g/dl
RDW : 14.6%
TC : 5,700 /mm³
DC : N – 07%, L – 61%,
E – 01%, M - 01%
Blast cell - 30%
Platelet Count: 19,000 / cu mm
To establish diagnosis

28. Peripheral blood film:
RBC - Normocytic, normochromic.
WBC - Shifting to left with many blast cells.
Platelets - Reduced.

29. Bone marrow study

30. 2. Bone marrow Study
• Cellularity : Hypercellular marrow.
• M/E ratio : Raised.
• Erythropoiesis : Depressed but normoblastic.
• Myelopoiesis : Hyperactive with shifting to
left.
• Megakaryocytes: Scanty.

31. Marrow is infiltrated by > 90 % blast cells
which contains scanty cytoplasm, condensed
chromatin, with 1-2 nucleoli morphologically
resembling lymphoblasts.
Comment: Acute lymphoblastic leukemia
(FAB L1)

32. 1. SGPT : 36 U/L ( up-40 U/L)
2. S. Uric Acid: 310 µmol/L (140 – 340 µmol/L)
3. B. Urea : 1.3 mmol/L (1.3- 5.8 mmol/L)
4. S. Creatinine: 44.2 µmol/L(40- 110 µmol/L)
5. S. Electrolytes : Na+
- 135 mmol / L
K+ -
3.5 mmol / L
Cl -
-100 mmol / L
6. S. Calcium : 2.2 mmol/L (2.02-2.6mmol/L)
Investigations
For assessment and management purpose
7. S. LDH: 245 U/L (81-234 U/L)

33. Investigations
08. S. Inorganic Phosphate: 3.5 mg/dl
(2.3-4.7mg/dl)
09. CXR : Normal findings

34. Infection screening
01. Urine R/E : Normal
02. Urine C/S : No growth
03. Blood C/S : No growth

35. Final diagnosis
Acute lymphoblastic leukemia (FAB L1)

36. Management

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

41. Consolidation: TIT
(6-8weeks) 6- MP
Cotrimoxazole

42. Interim maintenance phase : Vincristine,
(9-16 weeks) 6- MP
TIT
MTX
Cotrimoxazole

43. Delayed intensification phase : TIT
(17-20 weeks) Vincristine
Daunorubicin
L asperginase
Dexamethasone
Cotrimoxazole

44. Maintenance : ( Upto 2.5yrs)
Daily : Tab 6- MP
Weekly : Tab MTX
Tab Cotrimoxazole
Monthly : Inj Vincristin
Tab Dexamethasone
Every 3 mothly: TIT

45. Follow up
 15 days for 3 months.
 Monthly for 1year.
 3 monthly for next 2 years.
 6 monthly for another 2 years.
 Yearly, life long.

46. THANK YOU