BOF: 2.2
A 59-year-old male presents with a history of cough,
fever and pleuritic chest pain. He had been feeling unwell for several months,
complaining of feeling tired and breathless. He had consulted his GP about this and was noted to have
splenomegaly but this had been attributed to tropical splenomegaly syndrome as
he had spent several years in India and had had malaria several times. No
investigations had been performed as his symptoms of feeling tired and
breathless had been attributed to stress at work. He was not on any drugs; he
smoked heavily; 20 cigarettes a day for the last 30 years.
On examination he looked unwell, he was febrile, there
was no clubbing, there was consolidation in the base of his left lung and he
had hepatosplenomegaly.
Investigations:
Chest x-ray confirmed consolidation in the base of
his left lung.
Hb 7.6 g/dL
WBC 56.9 x 109/l
Neutrophils 41%
Metamyleocytes 8%
Myleocytes 21%
Promyelocytes 18%
Blast cells 9%
Nucleated red cells 3%
Platelets 49x109/l
The features are likely to be the result of a
complication of:
a)
Tropical splenomegaly syndrome
b)
Bacterial pneumonia
c)
Bronchial carcinoma
d)
Acute myeloid leukaemia
e)
Chronic myeloid leukaemia
Answer:
e)
The clinical features are not in keeping with tropical
splenomegaly syndrome and the patient would have had haematological features
of hyposplenism
If this were a leukaemoid reaction due to severe
bacterial pneumonia or due to marrow replacement by malignant cells from a
bronchial cancer infiltrating the bone marrow, this would not explain
long-standing splenomegaly. The
absence of clubbing would not favour bronchial carcinoma.
Acute myeloid leukaemia would not be supported by the fact that mature
forms are seen and there is a high neutrophil count.
Chronic myeloid leukaemia in its accelerated phase with
blast transformation is thus the most likely diagnosis and would explain all
the clinical features in this patient
Revision Tip
Revise chronic myeloid leukaemia
KEYS to SUCCESS in Medicine page 391-393
