Clinical Meeting on ALL

1. Welcome to
Clinical Meeting
Dr. Dhiman Saha
MD Part III
BICH

2. Particulars of the patient
• Name : Ronjila
• Age : 2 years 6 month
• Sex : Female
• Address : Bogra
• Date of admission : 02/11/16
• Date of examination : 03/11/16
• Informant : Mother

4. Presenting Complaints
• Fever for 1 month
• Progressive pallor for 1 month

5. History of Present Illness
According to the statement of informant
mother, Ranjila was well 1 month back. Then
she developed fever which was high grade
continuous in nature (highest recorded
temperature was 1040 F), not associated with
chills and rigor and subsided by taking
antipyretics. Mother also noticed that her child
getting progressively pale and generalized
weakness for last 1 month. She had no history
of cough, vomiting, convulsion.

6. H/O present Illness (contd.)
She also had no history of taking any
offending drugs, chemical exposure or even
traveling to endemic zone of kala-azar. With
these complains her mother consulted with
registered physician and was treated with oral
antibiotics, paracetamol syrup and referred to
SZMCH. There she received blood transfusion
for single episode, then they took DORB and
got admitted to DSH for further evaluation
and better management.

7. H/O present Illness (contd.)
As the condition was not improving, she was
referred to DSH for further evaluation and
better management.

8. History of Past Illness
There was no significant past illness.

9. Developmental History
Age appropriate
She was delivered by LUCS at term with
average birth weight without any complication.
Her postnatal period was uneventful.
Birth History

10. Feeding History
She was on exclusive breast feeding upto six
months of age then adequate complimentary
feeding was started. Now she is on family diet.
Immunization History
Immunized as per EPI schedule.

11. Treatment History
Before admission, she was treated with oral
antibiotic, paracetamol syrup and received 1
episode of blood transfusion. After admission
here she received blood transfusion twice and
got injectible antibiotic and oral antipyretic.

12. Family History
Ranjila is the second issue of non-
consanguineous parent. Other family members
are healthy. There is no history of similar illness
in her family.
Socioeconomic History
She belongs to a poor socioeconomic status,
lives in a tin-shed house, uses sanitary latrine
and drinks tube-well water.

13. General Examination
• Appearance - Ill-looking, toxic
• Anaemia - Moderately pale
• Jaundice -
• Cyanosis -
• Clubbing - Absent
• Koilonychia -
• Oedema -
• Dehydration -
• Bony tenderness - Present

14. General Examination contd.
• Lymph-node - Generalized lymphadenopathy involving
anterior and posterior cervical chains, Submandibular
region of both sides. Largest one measuring about 1.5
cm X 1 cm located at left anterior cervical chain. Lymph
nodes having smooth surface, firm consistency, mobile,
free from underlying structure and overlying skin
without any discharging sinus.
• Skin - BCG mark present. No bleeding manifestation
• Eye - Normal. No proptosis.
• Ear, nose, throat - Normal
• Signs of meningeal irritation - Absent

15. Vital Signs
• RR 36/min.
• Pulse 120/min.
• Temp. 1020F
• BP 95/60 mm of Hg

16. Anthropometry
• Height 94 cm
• Weight 12 kg
• WHZ - 1.5 SD
• HAZ 0.8 SD

17. Systemic Examination
• Mouth and Fauces No gum hypertrophy, no
mucosal petechie or purpura
• Anemia Moderately pale
• Jaundice Absent
• Lymph nodes Stated earlier
• Skin No bleeding manifestation
• Bony tenderness Present
Hemopoitic System

18. • Liver Palpable. 5 cm from right costal margin
along right mid clavicular line, non tender,
firm in consistency, having sharp border
and smooth surface. Upper border of liver
dullness in right 5th inter costal space.
• Spleen Palpable , about 3 cm along its long axis,
non tender, firm, smooth surface.
Hemopoitic System contd.

19. Examination of Other systems revealed
normal findings.

20. Salient Features
Ranjila, a 2 years 6 months old female child
presented with high grade continuous fever and
progressive pallor for 1 month. She had no
history of vomiting, convulsion or visiting any
endemic zone of Kala-azar. She was ill-looking,
toxic, febrile, moderately pale, bony tenderness
present, no gum hypertrophy or proptosis. There
was generalized lymphadenopathy with
hepatosplenomegaly without ascites. Other
systemic examination revealed normal findings.

21. Provisional Diagnosis
Acute Leukemia (most probably acute
lymphoblastic leukemia)

22. Differential Diagnosis
1. Acute Myeloid Leukemia
2. Kala-Azar

23. Investigations
To establish Diagnosis:
CBC
Hb 7.1 gm/dL
Total Count of WBC 7800/cu mm
Differential WBC Count
Neutrophil 10%
Lymphocytes 66%
Monocyte 04%
Atypical Cells 20%
Platelet Count 37,000/cumm

24. Investigation
Peripheral Blood Film
RBC - Anisochromia with anisocytosis
WBC - Atypical Cells are seen
Platelet - Reduced

25. Investigation
Bone Marrow study
Cellularity
Myeloid Erythroid Ratio
Erythropoisis
Granulopoisis
Megakaryopoisis

26. Investigations
For Assessment and Management Purpose:
• Serum Uric Acid
• Serum Electrolytes
• Serum Calcium
• Serum Phosphate
• SGPT
• Blood Urea
• Serum Creatinine
• Chest X ray
• Urine for R/M/E
• Urine C/S
• Blood C/S

28. Final Diagnosis
Acute Lymphoblastic Leukemia (FAB type )

29. Management
Counseling
About the nature of disease
Disease Course
Treatment option
Treatment available in our country
Treatment cost
Duration of treatment
Complication of disease and treatment
Outcome
Follow up

30. Management
Supportive
• Neutropenic diet
• Hydration with IV fluid 1500mL/day (3L/m2
Body surface area/day)
• Antipyretic (paracetamol- 1 and ½ tsf SOS)
• Antibiotic (Inj. Ceftriaxone 1gm IV once daily)
• Packed cell transfusion 10ml/kg

31. Risk based multi-staged protocolized
polychemotherapy
1. Induction of remission
2. Consolidation /CNS phase
3. Interim Maintenance Phase
4. Delayed Intensification phase
5. Maintenance

32. Induction of remission:
(1-5 weeks) Inj. Vincristine
Inj. L - asperginase
TIT (Hydrocortisone + MTX + Cytarabin)
Tab Dexamethasone
Tab Cotrimoxazol
Tab 6 -Mercaptopurine
Consolidation: TIT (Hydrocortisone + MTX + Cytarabin)
(6-8 weeks) Tab 6- Mercaptopurine
Tab Cotrimoxazol

33. Interim maintenance phase : Inj. Vincristine,
(9-16 weeks) Tab. 6- MP
TIT
Tab MTX
Tab Cotrimoxazole
Delayed intensification phase : TIT
Part I (17-20 weeks) Inj. Vincristine,
Inj. Daunorubicin,
Inj. L - asperginase
Tab Dexa
Tab Cotrimoxazole
Tab 6 -Mercaptopurine

34. Delayed intensification phase :
Part II (21-23 weeks) TIT
Inj. Cyclophosphamide
Inj. Cytarabine,
Tab 6 -Mercaptopurine

35. Maintenance : (21/2yrs)
Daily: Tab 6- Mercaptopurine
Weekly: Tab MTX
Tab Cotrimoxazole
Monthly: Inj Vincristin
Tab Dexamethasone
Every 3 mothly:
TIT (Hydrocortisone + MTX + Cytarabin)