The Infirmary

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[Transcription]

i have a case for you Dr. Lai if you would please

Background

Mr. Jones, a 39 year old man who worked in a factory manufacturing wood preservatives, noticed he was bleeding from his gums when cleaning his teeth and had been troubled by mouth ulcers for a couple of months. He was due to have a routine dental check up so he mentioned the problems to the dentist in the course of the consultation. The dentist confirmed the bleeding problem and mouth ulcers and suggested that Mr. Jones visit his GP as there was no underlying dental cause for the symptoms. Mr. Jones made an appointment to see his GP the following week but in the meantime he noticed he was becoming breathless, had developed a cough and was feeling generally “below par”.

On examination, the GP noted that Mr. Jones was pale, confirmed the oral symptoms and noted that Mr. Jones had lower left hand side chest signs. Abdominal palpation revealed a fullness on the left hand side below the rib margin. She finally observed that he had purpura below the knees.

The GP ordered a chest X ray and took a sample of blood for a full blood count (FBC), clotting screen and biochemical analysis.

Within 24 hours of receipt of the blood sample, a local Consultant Haematologist contacted the GP and asked her to refer Mr. Jones to the Haematology outpatient clinic the next day.

The consultant admitted Mr. Jones and requested further blood tests, performed a bone marrow aspirate and trephine biopsy and ordered an abdominal ultrasound. The results of the blood tests were as follows:


Haematology

Haemaglobin           70 g/L
White cell count           6x109/L
Neutrophils              0.5x109/L
Neutrophils appear hyposegmented and hypogranular on examination
Platelets              10x109/L
MCV                 108fL
B12 and folic acid           normal
Ferritin              400ug/L
NAP score             negative
Clotting Screen          normal





Biochemistry

Renal and hepatic functions    normal
Bilirubin             25mM/L

Bone Marrow Report
 
The bone marrow appeared hypercellular with evidence of increased apoptosis but with no megakaryocytic precursors present. Slight erythroid hyperplasia (1:1 ratio with white cells) was noted with 18% sideroblasts. Myeloblasts comprised 25% with many containing Auer rods and neutrophils were reduced but were hyposegmented and hypogranular as in the blood film.

Chest X Ray Report

Left sided pneumonia

Abdominal ultrasound report

Marginally enlarged spleen

Will i live, ahem he live ?
diagnosis and prognosis ?
justify your chosen methods to treat this patient aswell please.


Oh and my diagnosis of rai fei.

condition: dirty little teenage perv, needs a girlfreind.
symtoms: poor eyesight, lack of eye contact, peeling skin on the palm of his favourite hand, suspect stains on clothes/bedroom material/walls in conjunction with the strange dissapearance of everday cylindrical household objects.
treatment options: beat him, beat him some more, lock him up, force religion upon him, send him to an all boys school and forget about him until he's 30 and happily married.

[Mysthalin]

Mr. Jones clearly has radiation poisoning.

[Baine]

Mr. Jones is suffering the "this thread is fun only and only on a very low level of understanding so stick to Lai's examples" disease. Cure: gtfo

 

[Lai]

Thanks for the case, transcription!

Mr Jones

Blood tests says macrocytic anemia, thrombocytopenia, high ferritin and neutropenia. Platelets <20 explains the gum bleeding. Neutropenia explains the pneumonia. The hard part is deciphering the bone marrow report. If you take away the Auer rods and high blast myeloblast count then Myelodysplastic Syndrome would fit, but since those are present - Acute Myeloic Leukemia. As to what subtype, I don't really know, but the age (pretty stupid argument actually) and your question "justify your chosen methods to treat this patient aswell please" makes me think Acute Promyelocytic Leukemia (APL).

If it's APL - ~70% cure rate. I wouldn't tell patients percentages, besides it's the hematologists job who also have more methods of risk stratifying the patient.

Treatment - thrombocyte transfusion, intravenous antibiotics. For the APL (again hematologists line of work) All-trans retinoic acid, an acid form of vitamin A, allows differentiation of malignant promyelocytes to mature neutrophils, and chemotherapy.

[Mysthalin]

See, Leukemia is a cancer, and RP causes cancer. Therefore I win.

[Baine]

This was too easy to answer tbh.

[velocity78]

Case 1: Rai Fei

I think he maybe suffering from depression. His first symptom was the loss of interest in school. He is also ashamed of what he was/is doing which is why he doesn't give much eye contact and the tension between him and his mother.
 

[Transcription]

I do apologise if noboddy found my little case study fun, i always enjoyed doing them myself whilst i was studying haematology. I wont post anymore, my apologise.

[Lai]

I don't mind. You owe me the answer to your case at least

[Transcription]

If my memory serves me right it was M3 APL with sideroblastic anaemia and pneumonia. The age of the patient and the presence of the pneumonia would have affected the treatment options, with pneumonia obviously needing to be resolved prior to therapy; bearing in mind certain therapies would be ruled out with increasing age as they are considered too aggressive and are likely to kill the patient. The auer rods are important as they are pathognomic of AML, but you have the APL bang on as you know leukaemias are classified by the cell line in which they arise.

Fluorescent in situ hybridization (FISH) could be utilised to help confirm the classification as M3 leukaemias show a high frequency of t(15;17) translocations of the PML gene which codes for a transcription factor (forget which one), but basically the PML gene becomes fused with the RAR-a gene (which codes for a retinoic acid steroid hormone receptor) and forms a fusion protein which has the function of abnormal transcription causing proliferation which also blocks differentiation.

Ara-C, daunorubicin and thioguanine are commonly used in remission and consolidation therapy, with allogenic or autologous BM transplant required for curative therapy (remmission and currative therapy are not the same thing). Curative therapy is viable as the patient is under 55 meaning a reduced risk of graft versus host disease so.........Allogenic transplantation in combination with high dose ablative chemotherapy preferably.

but im by no means any kind of authority on this stuff, i only got a 2:1 on the case study when i did it myself. But tbh Lai ya did good. 

[Lai]

Cool. You've studied more hematology than we have. My role as a junior physician here is more to recognize if things are really fucked up and refer to specialist clinics. In this case it would be to see the alarming blood work and admit the patient to a haematology ward for more work-up. Maybe start him on antibiotics after consulting with a specialist in infectious disease and platelet transfusion with permission from hematology.

I added you to the list if you're interested

[velocity78]

So when do we see who's diagnosis was correct?

[Lai]

I try to space each segment with 24h in between. Too much work for me otherwise.

[velocity78]

ah ok

[Lai]

Case 1: Rai Fei

A boy of 13 years, Rai Fei, from Taiwan enters the examine room with his mother. His worried mother tells you that her son is staying up increasingly late at night by his computer. When she checked RaiFei's computer to see if he had completed his studying for the weekly chinese exam she found pictures of naked women, and to her astonishment he had not fully prepared for his weekly chinese exam! Rai Fei is adamant about the pictures being related to the sex-ed class.

Throughout the mother's history presenting Rai Fei gives you poor eye contact, seems disinterested and you can notice tension between mother and son. No apparent psychotic signs. Pregnancy, delivery and neonatal period normal. Birth weight 3216g. Previously healthy apart from a couple of episodes of otitis. Takes no meds as far as his mother knows. No allergies. His mother believes his son has gotten into drugs.

Your preliminary diagnosis is that Rai Fei has entered puberty. Depression is an important differential diagnosis. Change of sleeping patterns, decreasing interest in things he's previously found enjoyable (in this case school work) and poor emotional contact (eg. eye contact) are signs of depression. However, the above can all be attributed to normal behaviour for his age. http://www.psych.org/Share/Parents-Med-Guide/HTML-Physician-Depression.aspx#6. His poor eye contact is probably because he's ashamed of his behaviour. After all, he wasn't prepared for his weekly chinese exam! Rai Fei, like any teenager, probably also thinks being dragged to the doctor by mom is silly, thus showing disinterest in the ordeal.

From your vast personal experience in malpractice suits cancer is always good to have in mind. Brain tumor can explain a couple of the symptoms but there are no complaints of headache, nausea, somnolence nor any focal neurological symptoms. You write it off as a very unlikely possibility.

As you start to examine from top to toe, an odd finding stops you and make you think: his right breast is larger than his left breast. When you ask his mother about it, she says that this is new.

What primary condition do you suspect now?

How can you confirm your current suspicion in the physical exam (the first somatic sign)?

[Groundfire]

Annnd the plot thickens....

I still just think Ray Jay or wtf his name is, is just Horny with an urgent case of Procastabation.


But this enlarged breast intrigues me. Couldnt this still be a symptom of puberty? Maybe he has elevated estrogen levels for some reason.

[Lai]

I added you to the enlisted docs, Dr Groundy!

[Lai]

Btw, what does "Procastabation" mean?

[Groundfire]

Procasterbation:

The act of masterbating instead of doing something important. (ie. homework)

Example:
Two: Instead of doing that project, I was procasterbating.

http://www.urbandictionary.com/define.php?term=procasterbating

[Mysthalin]

I would also propose doing an estrogen and other hormone test. Perhaps it's another hormone at fault?

Also, order a scan/test on the larger brest, make sure there isn't a swelling or tumour underneath.