CLINICAL MICROBIOLOGY

February 4 – March 2, 2019

A Case study presented to the faculty of

Medical Laboratory Science
In partial fulfillment of the Internship Training for the
Degree of Bachelor in Medical Laboratory Science

Presented by: Graciella Faye N. Mayor

Clinical Instructor: Anna-Lee B. Bandoy, RMT, MSMT

Jason Chua, RMT
Marx Catalan, RMT, MSMT
I. Title
II. Author: Graciella Faye N. Mayor
Medical Technology Interns
University of the Immaculate Conception
Davao City
emayor28@gmail.com
February 2019

III. Definition of Keywords

Fossa ependymoma - a brain tumor arising from glial cells located in
the posterior fossa which is a small space in the lower part of the skull,
containing the hindbrain.
Apathy- Lack of interest
Remote tumor resection - Surgery is often used to remove all or part
of the tumor
Ventriculoperotoneal shunts (VPS) - is a surgical procedure that
primarily treats a condition called hydrocephalus. 
IV. Clinical History
Patient: 2 year old boy
History prior to admission: Recurrent bacterial infection

Chief complaint or pathologic consideration upon admission:

fever, apathy, vomiting, diarrhea of 24-hr and neck stiffness

Past medical history: Remote tumor resection

Immunizations: Well checked

V. Physical Examination: NONE

VI. Laboratory findings:
VII. Discussion

1. 5 Tests for work-up

 Presence of Philadelphia chromosome (though not limited to CML, but also for
AML). A shift to the left with blasts and excess basophils and eosinophils is
more indicative of CML than AML.

 CML and Leukemoid reaction have a common cause that will increase the
leukocytes it is either because of infection or necrosis. To tell the difference of
the two diseases, CML gives a low LAP score unless there is a concurrent
infection that’ll happen, while Leukemoid reaction yields a high score.
Splenomegaly is also more significant in CML than that of a leukemoid
reaction.

 CML is also confused with Angogenic myeloid metaplasia in which both

diseases produce immature peripheral blood leukocytes. They differ in the
numbers of NRBC’s in the blood film that is present in AMM (increased
NRBCs). The lap score of the AMM is usually in normal or increase.

2. Clinical impression
 First, an abnormal chromosome develops
A section of chromosome 9 switches places with a section of chromosome 22,
creating an extra-short chromosome 22 and an extra-long chromosome 9. The
extra-short chromosome 22 is called the Philadelphia chromosome, named for the
city where it was discovered. The Philadelphia chromosome is present in the
blood cells of 90 percent of people with chronic myelogenous leukemia.

 Second, the abnormal chromosome creates a new gene

The Philadelphia chromosome creates a new gene. Genes from chromosome 9
combine with genes from chromosome 22 to create a new gene called BCR-ABL.
The BCR-ABL gene contains instructions that tell the abnormal blood cell to
produce too much of a protein called tyrosine kinase. Tyrosine kinase promotes
cancer by allowing certain blood cells to grow out of control.

 Third, the new gene allows too many diseased blood cells
The tyrosine kinase caused by the BCR-ABL gene causes too many white blood
cells. Most or all of these cells contain the abnormal Philadelphia chromosome.
The diseased white blood cells don't grow and die like normal cells. The diseased
white blood cells build up in huge numbers, crowding out healthy blood cells and
damaging the bone marrow.

3. Vaccines received by the patient

 Peripheral blood smear shows basophilia and eosinophilia (most of them are
immature or in blast stages)
 Anemia is present
 Low grade-mild fever
  Bone pain
 Swollen glands
 Bleeding
 Bruises
 Splenomegaly
 Dyspnea
 Weight loss

4. Laboratory Findings and Correlation

 Increased bone marrow cellularity (myeloid cell line)
 PBS WBC count shows basophilia and eosinophilia
 Increased thrombocytes
 Decreased LAP score
 Presence of Philadelphia chromosome and/or BCR-ABL gene
 Blasts shifts to the left

5. Diagnostic Tests
 Flourescence in-situ hybridization is a test used to detect the BCR-ABL gene and
is also used to monitor treatment.
- The abl DNA shows up as a red dot in the microscope slide and bcr DNA
shows as a green dot. In Ph+ leukemic cells where bcr and abl are fused,
the dots appear together.

 Polymerase Chain Reaction can also be used to detect the BCR-ABL gene.
- Detects 1 abnormal cell mixed in with approx. 1 million healthy cells.

6. Treatment and Management

 Tyrosine Kinase Inhibitor
- Imatinib, Dasatinib, Nilotinib
 Protein Translation Inhibitors
- Omacetaxin
 Transplantation
- Allogeneic bone marrow transplantation
VIII. References

Chronic Myelogenous Leukemia (CML): Causes, Symptoms, Treatment.

(n.d.). Retrieved from https://www.webmd.com/cancer/lymphoma/cml-
need-to-know-first#2

Chronic myelogenous leukemia. (2016, May 26). Retrieved from

https://www.mayoclinic.org/diseases-conditions/chronic-myelogenous-
leukemia/symptoms-causes/syc-20352417

What Causes Chronic Myeloid Leukemia? (2018, June 19). Retrieved from
https://www.cancer.org/cancer/chronic-myeloid-leukemia/causes-risks-
prevention/what-causes.html

Keohane, E. M., Smith, L. J., & Walenga, J. M. (n.d.). Rodak's Hematology:

Clinical Principles and Applications (Fifth ed.). Quezon City, Philippines: C
& E Publishing.

Besa, E. C. (2018, December 06). Chronic Myelogenous Leukemia (CML) Treatment &

Management. Retrieved from https://emedicine.medscape.com/article/199425-
treatment

Treatment for Chronic Myelogenous Leukemia: TKIs, Immunotherapy, Chemotherapy,

and More. (n.d.). Retrieved from https://www.webmd.com/cancer/lymphoma/cml-
treatment-overview