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Running head: CASE STUDY 2

Case Study 2 for Advanced Pathophysiology


Lesley Davidson
Wright State University

CASE STUDY 2

Case Study 2 for Advanced Pathophysiology


1.) What is the most likely diagnosis in this patient? What is your rationale?
The most likely diagnosis for this patient is leukemia, specifically acute myeloid leukemia. Information
provided in the case study specific to this type of leukemia include clinical symptoms often presented in acute
myeloid leukemia such as intermittent epitaxis, and complaints of fever, fatigue, and malaise. There were also
symptoms of petechiae over the soft palate, a nonpruritic rash over extremities, trouble swallowing, and
multiple white plaques over the oral mucosa. Schiffer and Anastatsi (2013) stated, patients with acute myeloid
leukemia (AML) generally present with symptoms related to complications of pancytopenia (e.g. anemia,
neutropenia, and thrombocytopenia), including weakness and easy fatigability, infections of variable severity,
and/or hemorrhagic findings such as gingival bleeding, ecchymoses, epitaxis, and menorrhagia (Schiffer &
Anastatsi, 2013, p.1).
The hypertrophy of the gingivae is also characteristic of acute myeloid leukemia. Rao and Danturty
(2012) states, infiltration of gingivae, skin, or meninges is characteristic of monocytic subtypes (Rao &
Danturty, 2012, p.4). The hematological components of acute myeloid leukemia stated in the case study include
an increased white blood cell count, decreased platelets, increased uric acid levels, increased LDH levels, 68%
blastocytes, occasional Auer rods, and large prominent nucleoli. Zassadowski et al. (2008) stated, Auer rods
deriving from the crystallization of myelperioxidase (MPO) granules are the hallmark of acute myeloid
leukemia (Zassadowski et al, 2008, p.998).
2.) How is the absolute neutrophilc count (ANC) calculated, and what is it in this patient?
The absolute neutrophilic count (ANC) is calculated by adding both the percentage of
polymorphonuclear leukocytes and the percentage of the band neutrophils, multiplied by the total white blood
cell count. Sekeres (2013) states, the ANC can also be calculated by multiplying the total white blood cell
(WBC) count by the percentage of the polymorphonuclear cells (Sekeres, 2013, p.3). The ANC for this patient

CASE STUDY 2

is 17,200(0.02+0.01) =516 neutrophils. Neutropenia is defined as an ANC below 500 (Sekeres, 2013, p.3).
Because the patients ANC is 516, some signs or symptoms of infection may be demonstrated in this patient.
3.) What is the importance in the ANC?
The importance in the ANC is identifying the risk of obtaining an infection based on the absolute
neutrophil count. If the neutrophil count is low, the ability to fight infection is compromised. The patient should
be prescribed prophylactic antibiotics to prevent infection. Sekeres (2013) states, empiric antibiotic therapy
needs to cover both gram-negative and gram-positive bacteria (Sekeres, 2013, p.8).
4.) Do the evaluation findings point to any specific infections? Explain.
Based on the information provided in the case study in regards to the patient experiencing mid-chest
pain on swallowing only and mouth sores, would indicate inflammation/infection of the throat or thrush. Pagano
et al. (2012) states, invasive fungal diseases (IFD) are a leading cause of morbidity and mortality in severely
neutropenic patients, especially patients with acute myeloid leukemia (AML) and allogenic hematopoietic stem
cell transplant recipients (Pagano et al, 2012, p.1516). This patient also demonstrates a fever in addition to
neutropenia which would indicate infection. Heuser, Zapf, Morgan, Krauter, and Ganser (2010) stated, febrile
neutropenia (FN) has been used as an operative tem to describe incidence, characteristics, and outcomes of
patients likely to have an active infection during neutropenia (Heuser, Zapf, Morgan, Krauter, and Ganser,
2012, p.273).
5.) What would you expect this patients bone marrow to show?
Procedures used in diagnosing acute myeloid leukemia include a bone marrow biopsy or aspiration or a
peripheral blood smear. I expect this patients bone marrow to show replacement of normal cells of the marrow
by immature cells. Schiffer and Anastasi (2013) states, blast forms must account for at least 20 percent of the
total cells of the bone marrow aspirate (from a 500 cell differential count) to confirm bone marrow infiltration
(Schiffer & Anastasi, 2013, p.4). Older patients have a poor prognosis when diagnosed with this condition.
Larson and Klepin (2013) stated, older patients may also have decreased bone marrow regenerative capacity,
even after successful leukemia cytoreduction (Larson & Klepin, 2013, p.5).

CASE STUDY 2

6.) Should a lumbar puncture be performed on this patient? What is your rationale for your
answer?
A lumbar puncture is not indicated for this patient. To confirm a diagnosis of acute myeloid leukemia, a
bone marrow biopsy or aspiration is needed. In performing a bone marrow biopsy, tissue is taken from the
posterior superior iliac crest and spine. Zehnder (2013) states, the iliac crest is the only site at which both
aspiration and biopsy may be safely performed in an adult (Zehnder, 2013, p.3). A lumbar puncture is typically
indicated for viral, bacterial, or fungal infections; the patient does not demonstrate any neural deficits.
7.) What age-related changes would you be concerned with in the treatment of this patient?
Age-related changes I would be concerned with in the treatment of this patient would include losing
interest in performing activities of daily living, depression, failure to thrive, isolation from friends and family,
and being non-compliant to treatment. It is important that the patient has a good support system whether it be
friends or family. Hu, Wu, Jiang, Zhang, and Xu (2011) stated, even when eligible for treatment, elderly
patients may choose palliative care options or prematurely discontinue therapy (Hu, Wu, Jiang, Zhang, and Xu,
2011, p.2). There are treatment options for elderly patients in the management of older patients with acute
myeloid leukemia. Larson (2013) states, the management of older patients with acute myeloid leukemia is
difficult challenge. Older patients are more likely to have comorbidities that can limit treatment options; the
disease also tends to be more resistant to chemotherapy with more frequent unfavorable AML subtypes; thus,
the outcomes are worse than in younger patients (Larson, 2013, p.1).

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5
References

Heuser, M., Zapf, A., Morgan, M., Krauter, J., & Ganser, A. (2010). Myleoid growth factors in acute myeloid
leukemia:systematic review of randomized controlled trials. Annals of Hematology, 90, 273-281. doi:
10.1007/s00277-010-1069-z
Hu, R., Wu, Y., Jiang, X., Zhang, W., & Xu, L. (2011). Clinical symptoms and chemotherapy completion in
elderly patients with newly diagnosed acute leukemia; a retrospective comparison study with younger
cohort. BMC Cancer, 11(224), 1-8. Retrieved from www.biomedcentral.com
Keng, M., & Sekeres, M. (2013). Febrile neutropenia in hematologic malignancies. Cleveland Clinic Taussig
Cancer Institute, 1-27. doi: 10.1007/s11899-013-1017-4
Pagano, L., Caira, M., Candoni, A., Aversa, F., Castagnola, C., Caramatti, C., & Cattaneo, C. (2012).
Evaluation of the practice of antifungal prophylaxis use in patients with newly diagnosed acute myeloid
leukemia: results from the seifem 2010-b registry. Clinical Infectious Disease, 55(11), 1515-21. doi:
10.1093/cid/cis773
Zassadowski, F., Ades, L., Schlageter, M., Chevret, S., Guillemot, I., Fenaux, P., & Chomienne, C. (2008).
Auer rods and differentiation in acute promyelocytic leukemia. British Journal of Haematology, 142,
991-1002. Retrieved from www.ebscohost.com
Larson, R. (2013). Treatment of acute myeloid leukemia in older adults. Wolters Kluwer Health, 1-16.
Retrieved from www.uptodate.com
Larson, R., & Klepin, H. (2013). Pretreatment evaluation and prognosis of acute myeloid leukemia in older
adults. Wolters Kluwer Health, 1-7. Retrieved from www.uptodate.com
Schiffer, C., & Anastasi, J. (2013). Clinical manifestations, pathologic, features, and diagnosis of acute myeloid
leukemia. Wolters Kluwer Health, 1-13. Retrieved from www.uptodate.com
Rao, A., & Danturty, I. (2012). Leukemia cutis. Indian Journal of Dermatology, 57(6), 1-4. doi: 10.4103/00195154.103086

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Zehnder, J. (2013). Bone marrow apiration and biopsy:indications and technique. Wolters Kluwer Health, 1-24.
Retrieved from www.uptodate.com