Prepared by Porf. Dr. Gamal Esmat .

Presented by Dr. Ahmed Khairy .

Leukemia phase of lymphoma IV

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Staff round presentation

Prof.Dr. Gamal Esmat

Ass Prof.Hasan El Garem

Ass prof.Maissa El Razky

Dr.Mohamed Ibrahim

Dr.Ahmed Foad

Dr.Wafaa Elakel

Ass Lecture.Yasmin Saad

Ass Lecture. Dina Ismail

Dr. Mohamed Hamed

Dr. Mohamed Abdel hafez

By

Resident.Ahmed Khairy

•  Personal History

Admission : 5/8/2005

•  Male patient .

•  55 yrs old.

•  Married 35 yrs ago with 4 offsprings, youngest 16 yrs old .

•  Works as a farmer.

•  Born and living at Manwat Giza.

•  History of contact with canal water and received anti-schistosomal ttt in the form of injection and tablets.

Complaint

Pain in the Lt upper quadrant of the abdomen of 3 months duration (May 2005)

Present history

•  Started 3 months before admission by:

•  Lt hypochondrium dull aching pain, not radiating or referred, with no special precipitating or relieving factor.

•  Recurrent attacks of bilateral loin colicky pain radiating to the groin with no special precipitating or relieving factor.

•  Weight loss.

•  No fever, loss of appetite or night sweats.

•  No body masses or bony pains.

•  No history of jaundice, ascites, LL edema, hematemsis, melena, bleeding tendency or disturbed conscious level.

•  No history of recurrent infections.

•  No history of palpitation, dyspnea, dizziness or blurring of vision .

•  No history of travelling abroad.

•  No dysuria or frequency of micturition.

Past history:

- No DM - No hypertension

- No previous operations.

- No previous blood transfusion

- No history of drugs intake

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Family history:

No similar conditions

General examination

The patient is conscious, of average intelligence, well oriented to time, place and person , lying comfortably flat in bed. . BMI=63 / 1.75 2 = 20.5 . Pulse: 80/min, regular, average volume, no special character, equal on both sides. . Bp : 110 /70 . Temp :37.2 ( on admission )

Head & Neck

§ Pallor § No jaundice or cyanosis § Cervical lymph nodes : not palpable § Neck veins : not congested § Thyroid gland : not enlarged § Trachea : central

UL &LL . Inguinal LNs: . Two enlarged LNs (0.5-1 cm) on each side, firm, discrete, not tender . No palmar erythema, clubbing or LL edema

CVS & Chest : Free

Abdominal examination

§ Liver: - upper border: 5th space right MCL. - lower border: Rt lobe: not felt. Lt lobe: 2 fingers by light percussion § Spleen : enlarged 10 cms below Lt costal margin, firm in consistancy, smooth surface, rounded anterior border, preserved notch . § Kidneys : not felt § No ascites detected by shifting dullness

Summary:

•  Left hypochondrial pain

•  Bilateral loin pain

•  Weight loss

•  Huge Splenomegaly and pallor

Investigations

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On admission :

•  Renal function tests :

- Creatinine : 5.4 - urea : 120

- Abdominal US :

Bilateral parenchymal renal disease with back pressure changes and multiple stones.

Right upper hydroureter.

Left renal cyst.

- Plain UTI :
stone in lower right ureter and multiple left renal stones.

•  Double J catheter was inserted in the right ureter.

•  Follow up :

- Creatinine : 1.1 ( over 5 weeks duration)

- US : resolved back pressure changes

•  But the patient develops attacks of fever and dysuria

Liver biochemical profile

AST 8 (N:0 - 41)

ALT 11 (N:0 - 41)

Bilirubin ( total ) 0.37 (N:0.2 - 1.2)

Alkaline phosphatase 75 (N:40 - 150)

Total proteins 5.4 (N:6.4 - 8.3)

Albumin 2.8 (N:3.5 - 5)

LDH 245 U/L (N:125 -243)

PC 72 %

INR 1.32 

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Protein electrophoresis

•  Total protein : 5.0 g/dl

•  A/G : 1.46

•  Albumin : 2.8 g/dl (N: 3.5 - 5)

•  Alpha 1: 0.2 g/dl (N: 1- 0.35)

•  Alpha 2 : 0.6 g/dl (N: 0.65 -1.2)

•  Beta : 0.6 g/dl (N: 0.74 -1.26)

•  Gamma : 0.7 g/dl (N: 0.6 -1.7)

There is decrease in serum total protein & albumin

There is mild decrease in B-globulins

Kidney function tests:

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Abdominal Ultrasound: ( 4-9-2005)

- Liver : Average size, bright echopattern, smooth surface and normal hepatic veins. There is a hypoechoic focal lesion in segment v (mostly fat sparing area). No focal lesions or IHBR dilatation P.V. is not dilated.

-Gall bladder: Average size and wall thickness, no stones or mud inside. CBD is not dilated.

-Spleen : Hugely enlarged (longest axis is 24 cm) homogenous echopattern.

- The left kidney shows two stones in mid and lower poles & a small cyst 1.6 cm in diameter. No backpressure changes.

-Gall bladder:

Average size and wall thickness, no stones or mud inside. CBD is not dilated.

Conclusion:

-Bright liver with? Fat sparing area.

-Huge splenomegaly.

-Bilateral parenchymal renal disease with back pressure and multiple stones.

-Right upper hydroureter -Left renal cyst.

Hepatitis markers

Causes of increased b2 microglobulin

1-Glomerular renal diseases.

2-Multiple myloma.

3-Caner.

4-Collagen disorders.

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Post contrast CT abdomen & pelvis
Skeletal survey ( 1/10)
Bone marrow aspirate: ( 2/10 )
Splenic aspirate ( 5/10 )

Follow up CBC:

( 8/10 )

- RBCs: 2.9

HB: 7.1 MCV: 76.5 MCH: 76.5 MCHC: 31.5

- WBCs: 1.8

•  PTL: 276

(12/10 )

- RBCs: 2.5

HB: 6.3 MCV: 75.6 MCH: 24.3 MCHC: 32.2

•  WBCs: 1.1

Lymph: 70

Mono: 14

Blasts: 16

•  PTL: 178

Bone marrow biopsy:

Examination of serial sections reveled :

•  Hypercellular bone marrow with multifocal lymphoid infiltrate, inter & paratrabecular, with some are mature & some aren ' t mature.

•  Other haematopoietic tissues are markedly depressed.

•  Megarkaryocytic series is preserved.

•  Patchy areas of 2ry bone marrow fibrosis

•  Conclusion:

Leukemia phase of lymphoma IV

Thank you

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