CASE PRESENTATION

ACUTE MYELOID LEUKEMIA

Supervisor:
dr. Ulynar Marpaung, SpA

Adlina Zahra
 Outline
Case Illustration
Literature Review
Discussion
 CASE
ILLUSTRATION
 Identity
Name : Child NS
Date of birth : October 3rd 2011
Age : 5 years old
Gender : Female
Address : Batu Jamrud, Condet East Jakarta
Nationality: Indonesia
Religion : Islam
Date of admission : August 24th 2017
Date of examination : August 24th 2017
 Parents Identity

Father Mother
Name Mr. B Mrs. N
Age 32 years old 30 years old
J ob Entrepreneur Housewife
Nationality Javanese Javanese
Religion Islam Islam
Education Bachelor High School
Earning/month Approximately Rp 3.500.000,- -
Address Condet, East Jakarta
 Anamnesis

Chief complain
Severe headache since 1 day before admission
to the hospital

Additional complains: Bone pain, right eye

swelling
 History of Present Illness

5 months 4 months 4 months 3 months

ago ago ago ago

Nose bleeding 1st BMP

Fever and flu LCS 2nd BMP not
Tiredness examination Start 14 weeks fully remitted
Numb Chin Immunopheno chemotherapy (50% blasts)
Multiple Lumps at typing protocol Chemoterapy
skin Dignosed as continue
AML

Hospitalized
RSCM
at RS POLRI
 History of Present Illness

1 month 1 month August

Now
ago ago 2017

Continue
chemotherapy Massive
Severe whole Discharged Hospitalized at RS
headache and
body pain with good vital POLRI at Anggrek
body pain
Hyperleucocytosis lsign and ward for PRC
Gravis anemia
general transfusion
(4.1 g/dl)
appearance

Hospitalized
at RSCM RSCM
(20 days)
 History of Past Illness
Pharyngitis/Tonsilitis -
Bronchitis - The patients done 1 regiments
Pneumonia - of chemotherapy
Morbilli -
Pertussis -
Varicella -
Diphteria -
Malaria - Allergic History
Polio -
Enteritis - The patient didnt have cows milk allergy
Bacillary Dysentry - The patient didnt have asthma, allergic
Amoeba Dysentry - rhinitis, and atopic dermatitis
Diarrhea -
Thypoid - The patient didnt have allergic to medicine
Worms - The patient didnt have allergic to dust, pollen,
Surgery -
Brain Concussion -
etc
Fracture -
Drug Reaction -
 Mothers Pregnancy History
The mother routinely checked her pregnancy to the doctor in the hospital.
She denied any problem noted during her pregnancy. She took vitamins
routinely given.
Childs Birth History
Labor : Hospital
Birth attendants : Doctor
Mode of delivery : Pervaginam
Gestation : 38 weeks
Infant state : Healthy
Birth weight : 3000 grams
Body length : 50 cm

According to the mother, the baby started to cry and the baby's skin is red,
no congenital defects were reported
 Development History
First dentition: 6 months
Psychomotor development
Head Up: 1 month old
Smile : 1 month old
Laughing : 1- 2 month old
Slant : 2,5 months old
Speech Initation : 5 months old
Prone Position : 5 months old
Food Self : 5 6 months old
Sitting : 6 months old
Crawling : 8 months old

Mental Status: Normal

Conclusion: Growth and development status is still within normal limit and
was appropriate according to the patients age.
Immunization history

Immunization Frequency Time

BCG 1 time 1 month old
Hepatitis B 3 times 0, 1, 6 months old
DPT 3 times 2, 4, 6 months old
Polio 4 times 0, 2, 4, 6 months old
Hib 4 times 2, 4, 6, months old
 History of Disease in Other Family Members / Around the House
There is no one living around their home known for having the same condition
as the patient.

Sosial and Economic History

The patient lived at the house with size 10 m x 8 m together with father and
mother

Home ownership : private

Home condition : clean, good ventilation, good water condition
Environment : densely populated
Hygiene:

The patient changes his clothes everyday with clean clothes.

Bed sheets changed every two weeks.
 Physical Examination
General Status
General condition : Mild ill
Awareness : Compos Mentis
Pulse : 120 x/min, regular, full, strong.
Breathing rate : 24x/min
Temperature : 37.1oC (per axilla)
Saturation O2 : 98%
 Antropometry Status
Weight : 13 kilograms
Height :
a. Standing : 105 cm b. Sitting : 71.5 cm
 Nutritional Status based NCHS (National
Center for Health Statistics) year 2000:
WFA (Weight for Age): 13/18 x 100 % =
72 % ( good nutrition)
HFA (Height for Age): 105/108 x 100 % =
97 % (good nutrition)
WFH (Weight for Height): 13/17x 100 % =
76% (normal)

Conclusion: The patient has good nutritional status

General examination
Head
Normocephaly, hair (black, rare distribution or
almost bald, not easily removed ) sign of trauma (-)

Face
Numb chin (+)
 Eyes
Icteric sclera -/-, pale
conjunctiva +/+,
hyperaemia conjunctiva
-/- , lacrimation -/-,
sunken eyes -/-, pupils
cant be examined/3mm
isokor, direct and
indirect light response
-/+ and -
 Ears
AD: Normal shape, no wound, no bleeding, secretion or serumen
AS: Normal shape, no wound, , no bleeding, secretion or serumen
Nose
Normal shape, midline septum, secretion -/-
Mouth
Lips: moist
Teeth: no caries
Mucous: moist
Tongue: no dirty, normal
Tonsils: T1/T1, no hyperemia
Pharynx: hyperemia (-)
Neck
Lymph node enlargement (-), scrofuloderma (-)
 Thorax
Inspection : symmetric when breathing , no retraction,
ictus cordis is not visible
Palpation : mass (-), tactile fremitus +/+ normal
Percussion : sonor on both of lungs
Auscultation :
Cor: regular S1-S2, murmur (-), gallop (-)
Pulmo : vesicular +/+, Wheezing -/- , Rhonchi -/-
 Abdomen
Inspection : Convex, epigastric retraction (-),
there is no a widening of the veins, no spider
nevi
Palpation: supple, liver 2 cm below right costae
arch and 2 cm below prosessus xyphoideus and
spleen Schuffner 1, fluid wave (-),abdominal
mass (-)
Percussion : The entire field of tympanic
abdomen, shifting dullness (-)
Auscultation: normal bowel sound, bruit (-)
 Vertebra : There are no scoliosis, kyphosis, and
lordosis, no mass along the vertebral line
Extrimities : warm, capillary refill time < 2
seconds, edema(-)
Skin : Good turgor.
 Neurological Examination
Meningeal Sign
 Motoric examination Autonom examination
Power
Defecation Normal
Hand 5 5 5 5/ 5 5 5 5
Feet 5 5 5 5/ 5 5 5 5 Urination Normal ( 3-4 times daily )
Tonus
Sweating Normal
Hand Normotonus / Normotonus
Feet Normotonus / Normotonus
Trophy
Hand Normotrophy / Normotrophy
Feet Normotrophy / Normotrophy
Physiologic Refex
Upper extrimities
Biceps +/+
Triceps +/+
Lower extrimities
Patella +/+
Achilles +/+
Pathologic Refex
Upper extrimities
Hoffman -/-
Trommer -/-
Lower extrimities
Babinsky -/-
Chaddock -/-
Oppenheim -/-
Gordon -/-
Schaeffer -/-
Clonus
Patella -/-
Achilles -/-
 Complete blood count
August 24th 2017

Hematology Results Normal Value

Haemoglobin 4.1 g/dL 13-16 g/dL
Leukocytes 1.600 /L 5,000 10,000/L
Hematocrits 12 % 40 48 %
Trombocytes 61.000/ L 150,000 400,000/L
Erythrocytes 4,27 million/L 4 5 million/L

Ureum 24 10-50 mg/dl

Creatinine 0.5 0.5-1.3 mg/dl
Electrolytes
Natrium 142 135-145 mmol/l

Potassium 4.1 3.5-5.0 mmol/l

Chlorida 104 98-108 mmol/l
 Complete blood count
August 25th 2017
Hematology Results Normal Value
Haemoglobin 6.9 g/dL 13-16 g/dL
Leukocytes 1.900 /L 5,000 10,000/L
Hematocrits 20 % 40 48 %
Trombocytes 64.000/ L 150,000 400,000/L
Erythrocytes 2.5 million/L 4 5 million/L

August 26th 2017

Hematology Results Normal Value
Haemoglobin 9.9 g/dL 13-16 g/dL
Leukocytes 1.400 /L 5,000 10,000/L
Hematocrits 28 % 40 48 %
Trombocytes 56.000/ L 150,000 400,000/L
 WORKING DIAGNOSIS
ACUTE MYELOID LEUKEMIA
GOOD NUTRITIONAL STATUS
NORMAL GROWTH AND DEVELOPMENT
COMPLETE IMMUNIZATION
 Treatment
O2 3 l/m
IVFD RL 1150 cc / day
Inj. Cefotaxime 2 x 400 mg IV
Ketorolac 3x 10 mg
Initial PRC transfusion 150 cc
 Prognosis

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam
Quo ad sanationam: dubia ad malam
S Fever (-)
Fatigue (+), Headache with VAS 2-3
O General condition: Compos mentis.
Heart rate = 112 x/min
August 25th
Respiratory rate = 35x/min
Temperature = 36.5C 2017. Second
Eye: anemic conjunctiva +/+, right eye lump (+) day of
Cardio : S1/S2, reguler, murmur (+) , no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
hospitalization,
A Acute Myeloid Leukemia on kemoterapi 2nd day of
Anemia gravis ec susp.Chronic Disease (4.1 gr/dl)
illness
Susp. Retinoblastoma corneal ulcer
Leukopenia (1.600 u/l)
Trombositopenia (61.000 /ul)
P O2 nasal cannul 3L/m

IVFD RL 1150 cc / 24 hours.

Cefotaxime 2 x 400 mg IV

Ketorolac 3 x 10 mg IV

PRC transfusion target: 416 cc

st
1 day: 150 cc
S Headache (+) diminish
Fatigue (+)
Fever (-)
O General condition: Compos Mentis
Heart rate = 100 x/min
Respiratory rate = 30 x/min August 26th
Temperature = 36.2C
Eye: anemic conjunctiva +/+, right eye lump (+)
2017. Third day
Cardio : S1/S2, reguler, no murmur, no gallop of
Pulmonary : retraction (+) vesiculer +/+, rhonchi -/-, wheezing -/-
hospitalization,
A Acute Myeloid Leukemia on chemotherapy
Anemia gravis ec susp.Chronic Disease (6.9 gr/dl) 3rd day of illness
Susp. Retinoblastoma dd ulkus kornea
Leukopenia (1.900 u/l)
Trombositopenia (64.000 /ul)
P IVFD RL 1150 cc / 24 Hours.

Cefotaxime 2 x 400 mg IV

Ketorolac 3 x 10 mg IV

PRC transfusion target: 416 cc

2nd day: 250 cc

S Fever (-)
Breathless (-)
Productive cough (+)
O General condition: Compos mentis.
Heart rate = 98 x/min
Respiratory rate = 26 x/min August 27th
Temperature = 36.8 C
2017. Forth day
Eye: anemic conjunctiva +/+, right eye lump (+) of
Cardio : S1/S2, reguler, no murmur, no gallop hospitalization,
A
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
Acute Myeloid Leukemia on chemotherapy
4th day of illness
Anemia ec susp.Chronic Disease (9.9 gr/dl)
Susp. Retinoblastoma dd ulkus kornea
Leukopenia (1.400 u/l)
Trombositopenia (56.000 /ul)
P IVFD RL 1150 cc / 24 Hours.

Cefotaxime 2 x 400 mg IV

Ketorolac 3 x 10 mg IV

Discharge from hospital

Chemotherapy agent

Doxorubycin
Cytarabine
Metothrexat
ARA-C
Hydrocortison
Etoposide
LITERATURE
REVIEW
 Definition
Acute myeloid leukemia (AML) is a
heterogeneous group of leukemias that arise
in precursors of myeloid, erythroid,
megakaryocytic, and monocytic cell lineages

Jeffrey E Rubnitz, Brenda Gibson, Franklin O

Smith. Acute Myeloid Leukemia. Elsevier: 2010
Epidemiology
Physiology of Hematopoetic
 Etiology
Unknown
Mutifactorial, hypothesis:
Translocation may lead to the formation of a new gene,
whose expression may lead to a novel protein with
transforming capabilities
Patients with Down syndrome, Fanconi anemia, Bloom
syn- drome, ataxia-telangiectasia, Wiskott-Aldrich
syndrome, and neurofibromatosis 1 all have an
increased risk of acute leukemia

Karen Marcdante, Robert M. Kliegman.

Nelson Essentials of Pediatrics 7th edition. Elsevier: 2015
Patophysiology
 Clinical manifestation
Arthritis
Extremity Pain
Lymphadenopathy
Anemia
Bleeding
Hypercalcemia

Karen Marcdante, Robert M. Kliegman.

Nelson Essentials of Pediatrics 7th edition. Elsevier: 2015
 Diagnosis
History of the patient
Physical examination
Laboratory and imaging

Karen Marcdante, Robert M. Kliegman.

Nelson Essentials of Pediatrics 7th edition. Elsevier: 2015
 Common symptoms
Fever
Pallor
Petechiae or ecchymoses
Lethargy, malaise, anorexia
Bone or joint pain
 Physical examination
Lymphadenophaty
Hepatosplenomegaly
Specific tissue infiltration

Karen Marcdante, Robert M. Kliegman.

Nelson Essentials of Pediatrics 7th edition. Elsevier: 2015
 Laboratory and Imaging
Peripheral blood smear
Bone marrow aspirate
Blood count: abnormal, anemia and
thrombocytopenia
Definitive: Immunophenotyping
Lumbal puncture
Chest X-ray

Karen Marcdante, Robert M. Kliegman.

Nelson Essentials of Pediatrics 7th edition. Elsevier: 2015
 Classification

Modified from World Health

Organization Classification.
 Treatment
Patients with ALL generally receive three- or
four-agent induction chemotherapy based on
their initial risk group assignment.
Low- and standard-risk patients receive
vincristine, prednisone, and L-asparaginase for
4 weeks; high- risk patients also receive an
anthracycline (daunorubicin or doxorubicin)
Chemotherapy agents
THANK
YOU
Prognostic factors
 Differential Diagnosis

Non- Infection
Aplastic anemia
Juvenile rheumatoid
Infection arthritis
Epstein barr virus infection Immune
Cytomegalivirus thrombocytopenic
Pertusis purpura
Mycobacteria Congenital or acquired
conditions that lead to
neutropenia or anemia
Neuroblastoma
Rhabdomyosarcoma
Ewing sarcoma
Numb Chin Syndrom

Russel W Jenkins,Kristine McDonald. Numb Chin

Syndrome in Acute Myeloid Leukemia. American Journal
of Medical Sciences. 2012