Acute Myeloid Leukemia

Patient presentation
A 31 year-old male (K.G.) presents to emergency department with influenza-like symptoms, fatigue, tooth pain and loss of weight. In the past 48 hours, he has also had nausea, vomiting and some blood in his emesis and diarrhea. Pt has no prior significant medical history. No significant findings on assessment, he is slightly cachectic but in no apparent distress. Despite being on antibiotics for the tooth abscess, his WBC=127,000.

Differential list
Differential diagnoses include: infection, leukemia (chronic or acute).

Diagnosis
Lab results: CBC with diff and heme path review, CMP, Mg, Phos, Ca, blood and urine cultures, DIC panel, LDH, uric acid, coags.

Significant lab results: WBC=127,000 with 97% blasts (warranting a bone marrow biopsy and peripheral blood flow cytometry). Hgb 6.6, Hct 19.7, Plts 47, Albumin 2.5, LDH 729. Uric Acid 7.4. Blood and urine cultures negative.

Diagnostic Studies and Procedures: Peripheral blood flow cytometry and bone marrow biopsy (which is warranted due to the 97% blasts).

Diagnosis: Acute Myeloid Leukemia (type M1) (acute leukemia diagnosis for a primary bone marrow neoplasm equal or greater than 20% blasts).

Treatment:
Ordered labs: q12hrs CBC w diff, CMP, LDH, Uric acid, coags (initially while receiving chemotherapy to monitor for tumor lysis syndrome).  Check type and screen, FISH, CMV, Hep A, Hep B, Hep C, HIV, HLA typing (for potential bone marrow transplant).

Pretreatment procedures/tests: Place a central line catheter (for chemotherapy, blood products, antibiotics, IV support). Lumbar Puncture to evaluate CNS involvement. Chest CT. EKG. 2D Echo (to evaluate cardio function and ejection fraction due to cardiotoxic potential of chemo). Fertility counseling and possible fertility-preserving measures. Possible plasmapheresis to help decrease the WBC.

Medications/Interventions: Begin Hydrea® (for bone marrow suppression to help decrease peripheral blasts) while waiting for cytogenetic results. Also administer allopurinol to help body eliminate uric acid from cell breakdown. Closely monitor for tumor lysis syndrome. Begin induction chemotherapy (idarubicin, dexamethasone, cytarabine). Support patient with blood products, antibiotics, IV therapies, throughout treatment and while pancytopenic until absolute neutrophil count (ANC) recovers above 1,500 k/uL.

Outcome/prognosis:
After waiting for counts to recover for over 30 days, his post-chemotherapy bone marrow biopsy revealed 10% blasts remaining, resulting in a very poor prognosis (in addition to his poor cytogenetics). The only remaining curative option is bone marrow transplant.  Pt was re-induced with another regimen of chemotherapy.  Pt is currently receiving his 3rd regimen of chemotherapy before attempting an allogeneic bone marrow transplant (from his sister).