CASE PRESENTATION

Presented By :-
Dr. Tasmia Tabassum Ripa
Dr. Sayed Mahbub Raaj
Dr. Rajesh Lamichanne

Intern Doctors,
Department of Paediatrics,
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Anwer Khan Modern Medical College & Hospital
 PARTICULARS OF THE PATIENT:
• Name : Master Md. Mahim
• Age : 11 years
• Sex : Male
• Religion : Islam
• Address : Gopalgonj, Sadar
• Date of admission : 01.10.22
• Date of examination : 05.10.22
2
CHIEF COMPLAINTS:

1. Fever for 15 days.

2. Gradual pallor for 15 days.

3. Swelling in the neck for 7 days.

3
 HISTORY OF PRESENT ILLNESS:

According to the statement of patient’s mother, he was reasonably

well 15 days back then he developed fever, which was low grade,
intermittent in nature, highest recorded temperature was 100
degree Fahrenheit which was not associated with chills and rigor &

Subsided with sweating after taking Paracetamol. Fever was

associated with skin rashes all over the body.

 Contd…
There was also history of gradual pallor for same duration & associated with
Generalized weakness that interferes his day to day activities.

There were also history of multiple painless swelling in the neck for 7 days
which was gradually increasing in size & not associated with any discharge.

This problem was not associated with any headache, convulsion,

unconsciousness, alteration of bowel habit, cough, breathing difficulty,
bleeding from any site of the body, joint pain or history of contact with TB
patient.
 Contd…

On query, his mother said there was neither history of significant

weight loss nor any blood transfusion history.

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HISTORY OF PAST ILLNESS :
Nothing significant.

Drug history :
Nothing significant.
FAMILY HISTORY :
All family members are in good health. No history of non
consanguineous marriage. No known case of TB patient
present in family.
SOCIOECONOMIC HISTORY:
He belongs to a middle class family & lives in a
well ventilated house.
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BIRTH HISTORY :
He was delivered by lower uterine caesarean section and was
uneventful.

FEEDING HISTORY:
He was on exclusive breast feeding.
Now, he is on family diet, taking balanced diet.
IMMUNIZATION HISTORY:
He is duely immunized according to the EPI schedule.

Developmental History :
His development is appropiate to age.

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 GENERAL EXAMINATION

• Appearance : Ill-looking, pale

• Co-operation : Co-operative
• Decubitus : On choice
• Anemia : Severe
• Jaundice : Absent
• Cyanosis : Absent

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 • Clubbing : Absent
• Koilonychia : Absent
• Edema : Absent
• Leukonychia : Absent
• Dehydration : Absent
• Bony tenderness: Present
• Thyroid gland : Not enlarged
• Skin survey : BCG mark present. Petechial rash all over the
whole body.

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Lymph node:
Generalized lymphadenopathy involving the cervical and axillary
and inguinal region largest one was:
Pre-auricular : 6x6 cm.
Post auricular : 1.5x1cm
Sub mandibular : 2.5x2.5 cm.
Sub mental : 1x1 cm.
Juglo-diagastric : 2.5x2.5 cm
Anterior chain : 2x2 cm
Axillary lymph node : Medial group of node present
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• Shape : Irregular
• Consistency : Firm
• Margin : Ill defined
• Temperature : Not raised
• Tenderness : Absent
• Free from underlying and overlying structure.
• No discharging sinus.

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 VITAL SIGNS :

i. Temperature: 101* F
ii. Pulse: 136 beats/min
iii. Respiratory rate: 30 breaths/min
iv. Blood Pressure: 110/60 mmHg
v. SpO2: 98% at room air

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 SYSTEMIC EXAMINATION :
• LYMPHORETICULAR SYSTEM :
 Anemia – Severe

 Lymph nodes –
• Pre-auricular : 6x6 cm.
• Post auricular : 1.5x1cm
• Sub mandibular : 2.5x2.5 cm.
• Sub mental : 1x1 cm.
• Juglo-diagastric : 2.5x2.5 cm
• Anterior chain : 2x2 cm
• Axillary lymph node : Medial group of node present
• Inguinal region : 2x2cm in Both side
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 Contd…..
• Spleen – Enlarged.

12 cm from the left costal margin in the anterior

axillary line towards the right iliac fossa. Splenic
notch was present, margin was sharp, surface
smooth, non-tender, firm in consistency.

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• Alimentary System Examination:

Inspection:
 Mouth and Oral cavity: - pale tongue.
- no bleeding spot present.

 Abdomen: - Normal in size and shape.

- Umbilicus is centrally placed and inverted.
- No scar mark, visible pulsation and peristalsis.
 CONTD…..
Palpation:
Superficial palpation: -
 Temperature: normal
 Tenderness: absent

Deep palpation: -
 Liver : Enlarged measuring about 12.5 cm from the right costal margin
in the midclavicular line, margin-sharp, surface is smooth, and
firm in consistency. There were no hepatic rub or bruit.
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 CONTD……

 Spleen: Enlarged.
12 cm from the left costal margin in the anterior axillary line
towards the right iliac fossa. Splenic notch was present, margin was sharp,
surface smooth, non-tender, firm in consistency.

 Kidney: Bimanually not palpable & Non-ballotable.

 Bladder: Not palpable

 Para-aortic lymph nodes: Not palpable

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 CONTD….
Genitalia Examination:
Genitalia intact with no testicular swelling.

Percussion:
 Percussion note : Tympanitic
 Shifting dullness: Absent
 Fluid thrill: Absent

Auscultation:
 Bowel sound present

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• CARDIOVASCULAR SYSTEM :

Inspection – no visible cardiac impulse and

- no scar mark present.

Palpation – apex beat is felt in the left 5th ICS in midclavicular line.

- thrill , palpable P2 and left parasternal heave are absent.

 CONTD….

• Auscultation – 1st and 2nd heart sound audible.

- murmur absent.

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• OTHER SYSTEMIC EXAMINATION:
Reveals no abnormality

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 SALIENT FEATURE:
Master Md. Mahim , 11 years old Male, Muslim, first issue of non
consanguineous parents hailing from Gopalganj sadar presented with
Fever for 15 days which was low grade, intermittent in nature
associated with associated with petechial rashes all over the body and
gradual pallor with generalized weakness for same duration & history
of neck swelling for 7 days which was painless and gradually increasing
in size.
This condition is not associated with any headache,
convulsion, unconsciousness, alteration of bowel habit, cough,
breathing difficulty, bleeding from any site from any site from
body, joint pain or history of contact with TB patient. He was
on family balanced diet.

Clinically, child was ill looking, severely pale, febrile with vitals
BP-110/60 mm of hg, pulse rate- 136 beats/min, RR- 30
Breath/min, generalized lymphadenopathy with petechial rash
present and Organomegaly present.
 What is the

?
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probable diagnosis?
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 PROVISIONAL DIAGNOSIS :

Acute Leukemia

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DIFFERENTIAL DIAGNOSIS :

 Aplastic anemia
 Lymphoma
 Disseminated TB

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INVESTIGATIONS

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 CBC
29/09/22 2/10/22 3/10/22
( before blood ( before blood (Just after blood
transfusion ) transfusion ) transfusion)

Hb % 4.00 gm/dl 3.30gm/dl 5.90gm/dl

ESR 121 mm in 1st hr - 82mm in 1st hr

TC WBC 196.18x 10^9/L 140.00 x 10^9/L 102.00 x 10^9/L

TC RBC 1.57 x 10^12/L 1.32 x 10^12/L 2.18x10^12/L
TC PLATELETES 12 x 10^9/L 9.00 x 10^9/L 50.00x 10^9/L
DC OF WBC
• NEUTROPHILS 10 % 06% 4%
• LYMPHOCYTES 15% 06% 9%
• MONOCYTES 02% 5% 1%
• EOSINOPHILS 01% 0% 1%

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 STUDY OF PERIPHERAL BLOOD FLIM ON 02.10.22
 IMPRESSION –
1.RBCs : Anisochromic and anisocytic with roulex formation.
2.WBCs : Shows marked leucocytosis with gross shift to the left
predominant cell are blast morphologically lymphoblast.
3.PLATELETS : Reduced

 COMMENT - A case of acute leukemia favour lymphoblastic.

 ADVICE – Bone marrow examination and immunophenotyping.

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 BIOCHEMICAL TEST ON 3/10/22
Findings

S.Phosphate 5.40 mg/dl

S. Calcium 8.40 mg/dl

Uric Acid 5.40mg/dl

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 Serum Electrolyte (03/10/22)
Serum Electrolyte Result
Sodium 134 mmol/l
Potassium 4.6 mmol/l
Chloride 98 mmol/l
PCO2 25 mmol/l

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 BONE MARROW ON 03.10.22

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 IMMUNOPHENOTYPING ON 03.10.22

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 IMMUNOPHENOTYPING ON 03.10.22

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CONFIRMATORY DIAGNOSIS :

Acute lymphoblastic leukemia

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 TREATMENT
 Counseling done
Diet – neutropenic
Maintaince of hygiene by hand washing, foot wear etc.
Transfusion-1 bag of platelet transfusion & 2 unit of Packed Red Blood
Cell (PRBC) given.
Plan to start :
Chemotherapy : protocol based multi-staged polychemotherapy.

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CASE SUMMARY
 WHAT IS LEUKEMIA ?
• Leukemia is a malignant disease of the haemopoitic tissue,
characterised by replacement of normal bone marrow
elements with abnormal blood cells.

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 TYPES OF LEUKEMIA
 Acute myeloid leukemia(AML)
 Acute lymphoblastic leukemia(ALL)
 Chronic myeloid leukemia(CML)
 Chronic lymphocytic leukemia(CLL)

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 Acute Lymphoblastic Leukemia(ALL)
 Acute lymphoblastic leukemia(ALL) is a type of cancer that
affects immature lymphocytes developing in the bone marrow.

 Under normal conditions these cells grow and mature into

specialized white cells called B-lymphocytes(B-cells) and T-
lymphocytes(T-cells)

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 Causes Of ALL
 Ionizing radiation
 Chemicals
 Infections
 Electro-magnetic radiation
 Genetic factor

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 SIGNS & SYMPTONS OF “ALL”
 Anemia
 Increased bleeding
or bruising
 Frequent or
repeated infections
 Bone pain

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 INVESTIGATIONS :
• Full blood count- Anemia, thrombocytopenia, leucopenia or
leukocytosis

• Peripheral smear study- Total leucocyte count raised , normal

or low, Normocytic normochromic anemia, Thrombocytopenia

• Coagulation studies (prothrombin time [PT], activated partial

thromboplastin time [aPTT], fibrinogen)
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• Renal profile and liver function test- due to tumour lysis
syndrome, need to monitor hyperkalemia, hyperuricaemia,
hyperphosphotemia and hypocalcemia

• Bone marrow aspiration and biopsy- hypercellular

replacement of normal cells by blast cells which more than 20%.

• Blood cultures- obtained in patients with fever and other signs

of infection.
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 Bone Marrow Aspiration and Biopsy

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 CONTD….
• Lumbar puncture- used to evaluate CNS involvement.
• In pediatric patients, LP is typically included in the diagnostic workup. CNS
status is classified as follows, on the basis of cerebrospinal fluid (CSF)
findings:
1. CNS-1: No lymphoblasts in CSF, regardless of white blood cell (WBC) count
2. CNS-2: WBC < 5/mcL in CSF with presence of lymphoblasts
3. CNS-3: WBC 5/mcL in CSF with presence of lymphoblasts
• Chest x ray- Nodular masses. Central lymphadenopathy, such as mediastinal
lymph node enlargement.
• Computed tomography scans- can further define the degree of
lymphadenopathy in some patients, including those with mediastinal masses.

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 MANAGEMENT OF ALL :

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 Induction phase
The primary goal of induction is achievement of an initial complete
remission (CR), defined as the eradication of ALL detectable
leukemia cells (less than 5 percent blasts) from the bone marrow
and blood and the restoration of normal hematopoiesis (>25
percent cellularity and normal peripheral blood counts). involves
either a four-drug regimen of vincristine, prednisone, an
anthracycline, and cyclophosphamide or L-asparaginase or a five-
drug regimen of vincristine, prednisone, an anthracycline,
cyclophosphamide, and L -asparaginase given over the course of 4-
6 weeks.
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 Consolidation therapy
• The goal of post-induction chemotherapy is to prevent leukemic regrowth, reduce
residual tumor burden, and prevent the emergence of drug-resistance in the
remaining leukemic cells.
• Cytarabine

• Methotrexate

• Anthracyclines (daunorubicin, doxorubicin)

• Alkylating agents (cyclophosphamide, ifosfamide)

• Epipodophyllotoxins (etoposide, etopophosphamide)

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 Maintenance therapy
After completion of the consolidation or intensification phase
of therapy, patients often receive a less intensive continuation
regimen (eg maintenance chemotherapy) using daily oral 6-
mercaptopurine (6-MP), weekly methotrexate with periodic
vincristine, prednisone, and intrathecal therapy.

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 Supportive therapy
• Packed red blood cells are given to patients with a hemoglobin level of less
than 7-8 g/dL or at a higher level if the patient has significant cardiovascular
or respiratory compromise.
• Platelets are transfused if the count is less than 10,000-20,000/A. Patients
with pulmonary or gastrointestinal hemorrhage receive platelet transfusions
to maintain a value greater than 50,000/4L. Patients with central nervous
system CNS hemorrhage are transfused to achieve a platelet count of
100,000/4L.
• Fresh frozen plasma is given to patients with a significantly prolonged
prothrombin time (PT).
Cryoprecipitate is given if the fibrinogen level is less than 100-125 g/dL.
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