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Hematology Case Management

Hematology Case Management. History. General Data Patient is RB, 30/F from Pandacan, Manila, Jehovah’s Witness, nonsmoker, non-alcoholic beverage drinker, nonasthmatic, nondiabetic, nonhypertensive Chief complaint Gum bleeding. History of present illness

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Hematology Case Management

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  1. Hematology Case Management

  2. History • General Data • Patient is RB, 30/F from Pandacan, Manila, Jehovah’s Witness, nonsmoker, non-alcoholic beverage drinker, nonasthmatic, nondiabetic, nonhypertensive • Chief complaint • Gum bleeding

  3. History of present illness • 5 months prior to admission: Px noted recurrent hematoma and ecchymoses on her upper extremities. These would disappear spontaneously after 2 to 3 weeks. No consults/meds taken. • 4 months PTA: Px consulted at PGH OPD and her CBC showed a decreased platelet count. She was on regular follow-up at the OPD and was eventually referred to hematology.

  4. 3 months PTA: She was seen at the hematology OPD where she was given prednisone 20mg PO to be taken 3 times in the morning and 2 times during the evening. Bone marrow aspiration was also done. • 2 months PTA: BMA results showed AML. Prednisone was gradually tapered then discontinued last January 6, 2010. Px is on regular ff-up c/o hematology OPD. Px had no signs and symptoms of bleeding but still with low platelet count.

  5. 2 months PTA (Feb. 14, 2010): Px had epistaxis and gum bleeding and was rushed to the ER. She was eventually admitted at the ward and discharged 10 days later until • 9 days PTA: She was on her scheduled consult at the Cancer Institute when her CBC showed a platelet count of 20. She was then referred to the ER for low platelet and presence of gum bleeding and was admitted at the ward 2 days later.

  6. Review of systems • (-) difficulty breathing • (-) fever • (+) easy fatigability • (-) epistaxis • (-) melena • (-) hemarthrosis • (-) hematuria • (-) hematochezia

  7. Past Medical History • No history of goiter, heart problem, liver problem, kidney problem, allergy • Family Medical History • Non-contributory

  8. OB/Gyne History • G5P5 (5005): 1st 4 children via SVD, youngest via cesarean section for breech presentation • No fetomaternal complications • Regular monthly menses, lasting 3-4days, consuming 3 pads/day, (-) dysmenorrhea • (+) OCP use (2006-2008) • (-) IUD/BTL use

  9. Personal/Social History • Px works as a housewife. Her husband works as a mechanic. They live with her brother-in-law and his family. All children stopped going to school starting this year. • No vices, denies exposure to toxins/secondhand smoke

  10. Physical Examination • General Survey: awake, conversant, not in cardiorespiratory distress • Vital signs: BP 90/60, HR 92 bpm, RR 18/min, temp 36.8 • HEENT: pale conjunctivae, anictericsclerae, (-) CLAD, (+) TPC, (-) gum bleeding, (-) epistaxis • Chest/lungs: equal chest expansion, clear breath sounds, (-) rales, (-) rhonchi, (-) wheezes, adynamicprecordium, distinct heart sounds

  11. Normal rate, regular rhythm, no murmurs • Abdomen: flat, normoactive bowel sounds, soft, (+) slight epigastic tenderness on deep palpation, (-) guarding, (-) masses, (-) organomegaly • Skin/extremities: pale nailbeds, full and equal pulses, (-) cyanosis, (-) edema, (-) jaundice, (+) multiple erythematousmacules on bilateral lower extremities

  12. Course in the ER and Wards • February 26, 2010: Px was at Cancer Institute and OPD for her regular check-up. Her CBC showed Hb 94, hct 0.28, plt 20, and WBC 36.7. She was immediately referred to the ER for admission due to her low plt and (+) gum bleeding. • February 27, 2010: Px was seen by Hematology Service. BT of platelet concentrate was ordered.

  13. February 28, 2010: Px was seen by the Day MHAPOD. BT of 6 ‘u’ PC and tranexamic acid 500mg cap q8 was ordered. Px was admitted at Ward 1. • March 2, 2010: s/p BT of 4 ‘u’ PC. Px still had gum bleeding. Additional 6 ‘u’ PC was ordered. CBC showed Hb 90, hct 0.267, plt 10, WBC 37.6, RBC 2.64, blast 0.73. Px also complained of epigastric pain. She was given omeprazole 20 mg/tab OD and ribamipide 100mg TID.

  14. March 3, 2010: s/p BT 4 ‘u’ PC. Px still has gum bleeding. For transfusion again of 6 ‘u’ PC. Px noted decrease in epigastric pain. • March 5, 2010: s/p BT 5 ‘u’ PC. Px had fever and chills but no cough, abdominal pain, dysuria, or pallor. Post BT CBC showed Hb 80, hct 0.232, plt 21, WBC 40.1, RBC 2.32, blast 0.77, band/stab 0.01, promyelocyte 0.08. For BT of 6 more ‘u’ PC.

  15. March 6, 2010: Px had no more fever, active bleeding, cough, and colds. On PE, (+) tonsillar walls congested with exudates. A> ATP. Px was given cefuroxime 750mg IV q8 and paracetamol 500mg/tab q4. UA and CXR were ordered. • March 7, 2010: s/p BT 6 ‘u’ PC. Px had no new subjective complaints. Still with tonsillopharyngeal wall congestion. Present management continued.

  16. Assessement • Acute myelogenous leukemia • Acute tonsillopharyngeal congestion

  17. Acute Myelogenous Leukemia

  18. Acute Myelogenous Leukemia • Malignant bone marrow disease • Hematopoietic precursors arrested in an early stage of development through activation of abnormal genes through chromosomal translocations and genetic abnormalities • More common in men and in whites, affecting all age groups

  19. Risk Factors: • Antecedent hematologic disorder • Congenital syndrome • Heredity • Environmental exposure • Radiation, smoking, benzene • Exposure to chemotherapeutic agents • Alkylating agents aberrancy in chromosomes 5 & 7 • topoisomerase-II-inhibitors  aberrancy in 11q23

  20. French-American British (FAB) Classification

  21. Symptomatology • Nonspecific, beginning gradually or abruptly and often related to anemia, thrombocytopenia, leukocytosis or leukopenia: • Fatigue • Exertional dyspnea • Dizziness • Anginal pain • Fever with or without infection • Bleeding/easy bruising

  22. Symptomatology • Symptoms from organ infiltration by leukemic cells: • Early satiety • Gingivitis • Respiratory distress • Altered mental status • Bone pains

  23. Physical Findings • Fever • Splenomegaly • Hepatomegaly • Lymphadenopathy • Sternal tenderness • Bleeding • Signs of infiltration of gums, skin, soft tissues, meninges

  24. Hematologic Findings • Anemia • Leukocytosis, leukopenia, or normal WBC count • Presence of Auer rods • Thrombocytopenia

  25. Auer Rods -clumps of rod-shaped azurophilic granular material seen in the cytoplasm of leukemic blasts -composed of fused lysosomes and contain peroxidase, lysosomal enzymes, and large crystalliine inclusions When present, myeloid lineage is certain

  26. AML Management

  27. Diagnostics • CBC • Leukocytosis • May also present as thrombocytopenia, anemia or leukopenia • Peripheral blood smear • Confirms CBC findings • Presence of circulating blasts

  28. Diagnostics • Blood chemistry profile • Usually with elevated LDH and uric acid levels • Bone marrow aspirate and biopsy • > 20% blasts; Auer rods • Evalueates degree of dysplasia • Immunophenotyping (Flow cytometry) • Distinguish AML from ALL • Further classify into subtypes

  29. Therapeutics • Chemotherapy as the primary treatment • Induction Phase • Postremission Phase • Supportive care

  30. Induction Chemotherapy • Often combination therapy with cytarabine and anthracycline (7 and 3 regimen) • Cytarabine: continuous IV infusion for 7 days • Daunorubicin IV on days 1, 2, and 3 • Check BM after induction • if > 5% blasts exist with > 20% cellularity  re-treat or change the therapy • Allogeneic SCT recommended after two failed induction courses

  31. Supportive Care • Recombinant hematopoietic factors • Platelet transfusions • pRBC transfusion • Early initiation of empiric antibacterial and antifungal antibiotics

  32. Postremission Therapy • To eradicate residual leukemic cellsto prevent relapse and prolong survival • High-dose cytarabine (3 g/m2 every 12h on D1,3, and 5) effective than standard dose (100 mg/m2 per day for 5 days by continuous infusion) • Allogeneic SCT used in patients <70 years and with HLA-compatible donor

  33. Relapse • Patients eligible for allogeneic SCT should receive transplant at the first sign of relapse • Poor outcome of early relapse patients (<12 months) • Patients with longer first CR (>12 months) have higher chance of attaining CR but cure is uncommon • For elderly patients (>70years) –antibody-targeted chemotherapy (gemtuzumab ozogamicin) has a CR rate of ~30% • Consider exploring novel approaches

  34. Agents under Study for AML Treatment in Adults

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