Haematology Revision Course August 2013 (MEQ)

TRIGGER 1

35 years old man presented with gum bleeding, intermittent fever, and reduced effort
tolerance for a week. There is also bilateral lower limb weakness and acute urinary retention
for 3 days. On examination noted he is pale and there were petechial and bruises on his trunk
and lower limb. BP 100/60mmHg, PR110bpm, T 38 ⁰C, power both lower limb 3/5 and
Babinski’s sign positive bilaterally. Hb 7, WBC 3, Plt 15, PT 1.8, aPPT 65, fibrinogen 0.9

A) List the relevant investigations that you would like to do:

B) What is your provisional diagnosis?

C) Plan your Immediate management:

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TRIGGER 2

Urgent MRI confirmed cord compression at L1 level by paravertebral soft tissue mass. On
further questioning, he gave history of acute leukemia 5 years ago. No other significant medical
history. He has 4 siblings and they are healthy.

D) Describe the PBF

E) How would you manage this case?

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TRIGGER 3

He was admitted for febrile neutropenia post chemotherapy. His vitals were stable and broad
spectrum antibiotics initiated after septic work up. He was given packed cell transfusion due to
anaemia. One hour into transfusion developed chills and rigors, dyspnoea and palpitation. BP
80/40mmHg, PR 120bpm, SPO2 88%, Tempt 39⁰C

F) What is the Differential Diagnosis?

G) How would you manage at this point

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TRIGGER 4

A diagnosis of TRALI was made and he was managed according. He recovered uneventfully and
discharged in 2/7. He underwent chemotherapy smoothly and was discharged to clinic after
completing treatment. Two years later, he presented with history of spontaneous bruises on
his lower limb for 2 days. He denied any fever and he was not on any traditional medicine.
Physical examination unremarkable, apart from ecchymosis on her trunk and lower limbs. His
blood investigation showed Hb 11, WBC 6, Platelet 155, aPTT 85, PT 1.2 RP/LFT normal

H) How would you approach?

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TRIGGER 5

Factor 8 inhibitor study

aPTT normal 3205 26-38.9

aPTT patient 69.6 26-38.9
Mixing 49 26-38.9
F VIII C 1.8 70-150
CT Scan of Neck, thorax, Abdomen and Pelvis: normal

CTD Screening: normal

One day later, developed massive soft tissue bleeding and Hb dropped to 5g/dL.

Clinically tachycardia with BP 90/45mmHg

aPTT aPTT mixing IX:C Factor 9i VIII:C Factor 8i

normal patient
32.5 69.6 49 20.7 negative 1.8 121.6

I) Diagnosis:

J) Immediate Treatment

TRIGGER 6

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His APML relapsed 5 years later and given salvage chemotherapy then underwent
myeloablative allogenic haematopoeitics stem cell transplant (HSCT) from his HLA fully matched
sibling. The procedure went uneventfully until Day14 post infusion when he developed massive
diarrhea (>1.5litre/day). No fever and his BP was 85/45mmHg, PR120bpm. Bloods showed Hb
10, WBC 3, Platelet 50, Urea 15, Creat 200, Bil 35, AST 100, ALT 110

K) Possible Diagnosis

A colonoscopy was done and biopsy was consistent with GVHD, he recovered with treatment
and discharged after 3/51 later. Came for fever for 2 days. Clinically unremarkable. His
cyclosporine, bactrim, penicillin and acyclovir were continued. Hb10, WBC 1.5, Plt 35, T.Prot 65,
alb 30, Bil 35, ALT 300, AST 250, GGT 450.

L) Differential diagnosis

TRIGGER 7

Hepatitis screening done with results as below

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HepBs Ag negative
Anti HepBs ab negative
HepBe Ag negative
Anti HepBe ab negative
Anti HepBc IgM negative
Anti HepB c IgG detected
Hep C Ab negative
CMV lgM negative
CMV IgG positive

M) Further history to illicit:

HBV DNA sent showed 1000IU/ml

N) What is the diagnosis?

O) Management with regards of the above result?