1. NYU Medicine Grand Rounds Clinical Vignette Maryann Kwa, MD PGY-2 January 12, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 39-year-old man presenting with fever, chills, and a non-productive cough for one week. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was in his usual state of good health until six months prior to admission, when he began to note a gradual weight loss. One week prior to admission, he started having fevers up to 101˚. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. The fevers were accompanied by chills, night sweats, and an intermittent dry cough. Given concern over his symptoms, he presented to the Bellevue Hospital emergency room. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: None Past Surgical History: Appendectomy at age 16 Social History: He was born in New York. He works as a cook in a restaurant. He denied tobacco, alcohol or drug use. Family History: Mother, alive at age 65, with breast cancer Allergies: No Known Drug Allergies Medications: Multivitamin daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination General: Well-developed young male who appeared fatigued and in no acute distress Vital Signs: T: 100.9 BP: 120/80 HR: 90 RR: 16 and O2 sat: 95% room air Abdomen: Palpable spleen tip Extremities: Trace lower extremity edema bilaterally to knees Lymph nodes: Shoddy 1 centimeter lymph nodes palpated in bilateral axilla and right inguinal region The remainder of the physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings CBC: Hemoglobin/Hematocrit 9.0/27 MCV 87 Platelets 256 White blood cell count 11.0 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings White blood cell count differential: Neutrophils 56% (44-70) with 4% bands (2-8) Lymphocytes 16% (20-45) Monocytes 4% (2-10) Basophils 7% (0-2) Eosinophils 1% (1-4) Metamyelocytes 2% (<=0) Myelocytes 4% (<=0) Promyelocytes 2% (<=0) Blasts 3% (<=0) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings Basic Metabolic panel: Creatinine 1.3 Remainder of basic was within normal limits Hepatic panel: within normal limits International normalized ratio: within normal limits Partial thromboplastin time: within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Acute myeloid leukemia, versus chronic myeloid leukemia with blast crisis, versus lymphoma Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Additional Laboratory Studies Lactate dehydrogenase: 502 (110-225 U/L) Haptoglobin: 435 (30-200 mg/dL) Reticulocyte %: 1.99 (0.5-1.5) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Additional Laboratory Studies Iron: 50 (42-146 ug/dL) Total iron-binding capacity: 310 (250-450 ug/dL) Ferritin: 650 (22-322 ng/mL) Peripheral Smear: numerous immature white blood cells including blasts, normal red blood cells and platelets U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. CAT Scan Chest U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Day 1: –Bone marrow biopsy was performed. –Flow cytometry and cytogenetics were sent. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Days 2 and 3: –Bone marrow biopsy showed hypercellular marrow with 20% blasts. –Immunophenotyping showed immature cells positive for CD13, CD 33, CD 34, CD 117 and myeloperoxidase. –Cytogenetics revealed translocation between chromosomes 8 and 21 [t(8;21)]. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21 Revised Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Hospital Day 4: –The patient was started on induction chemotherapy with 7 days of cytarabine and 3 days of idarubicin (“7+3” regimen). Hospital Day 15: –The patient tolerated chemotherapy well and was discharged home with outpatient oncology follow-up. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

18. A repeat bone marrow biopsy showed complete remission after induction chemotherapy. The patient is currently awaiting consolidation therapy. Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

19. Acute myeloid leukemia (AML) with translocation between chromosomes 8 and 21, responsive to induction chemotherapy, now in complete remission. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS