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     UNITED STATES
      
     Nishant Sharma
     8 Mead Street # 2
     Allston MA 02134
     USA

     Ph.:
     Mobile : 858-229-3427
     Landline: 617-987-2383
     E-mail :      contact@savesukriti.org

     INDIA

     Dr. Ravi Pathak
     FC-125, Tagore Garden
     New Delhi - 110027
     INDIA

     Ph.: + 91 - 9810412536
     E-mail :      contact@savesukriti.org

                        Sukriti's Story

Presented with history of fever - 3 episodes of 5-6 days duration in 2 months associated with URI. H/O few bruises on lower limbs. O/E : No LN, No hepatosplenomegaly, no sternal tenderness.

Haemogram: Hb 9.6 gm/dl TLC 3,100/ mm3 Platelets 92,000/mm3, PS : Atypical monocytoid cells.

Bone marrow: (14/9/02) : Marked increase in blast cells with high N/C ratio, 2-4 prominent nucleoli, moderate amount of pale cytoplasm and auer rods in some of cells. Blast cells - 46% S/O Acute leukemia.

Phenotyping: T cell markers (CD3) 8.98%, B Cell markers (CD19) 1.77%
Myeloid markers (CD13) 63.7% (CD33) 88.98%

Diagnosed as a case of AML M2.

Ist Cycle of Induction Chemo (Started on 14-09-2002)
Inj Daunorubicin 20mg/m2 D1-3
Inj Cyrabine 250mgX24hrs D1-5
Inj Etoposide 200mgX24hrs D4-5

Bone marrow (12-10-2002) : Myeloblast 18% Promyelocytes 4% Hypocellular marrow with erythroid hyperplasia and increase in myeloblasts.

Planned to treat her according to 'AML 12' protocol from then onwards.

2nd Cycle of Induction Chemo (Started on 14-10-2002)
Inj Mitoxantrone 12 mg in 500ml NS over 6 hrs (D1,3,5)
Inj Cytrabine 100mg slow I/V push 12 hrly X10 days (20 doses)
Inj Etoposide 100mg in 250 ml NS over 2 hrs (D1-5)

ANC remained <500/mm3 till D26. Blood cultures & Urine cultures - (Neg.)
Supportive care included broad spectrum antibiotics (including few doses of amphotericin B), 4 units of platelet Pharesis, 4 units of packed cells.

Bone marrow (14-11-02) : Myeloblasts 2% promyelocytes 4% Myelocytes 8% Metamyelocytes 12% M:E ratio 1.2:1, Mild hyperplasia with increase in predominantly late & intermediate normablasts, Myeloid series show no evidence of hyperplasia. No increase in myeloblasts.

3rd Cycle of Induction chemotherapy (started on 19-11-02)
Inj Mitoxantrone 12 mg in 500 ml NS over 6 hrs (D1,3,5)
Inj Cytrabine 100 mg slow I/V push 12 hrlyX8 days (16 doses)
Inj Etoposide 100 mg in 250 ml NS over 2 hrs (D1-5)
ANC remained <500/mm3 till D24. Supportive care included broad spectrum antibiotics including Meropenem. Required Amphotericin B. Required high dose of parenteral K+ supplementation (~160mEq/day) due to increased renal loss (TTKG~10). Required three units of platelet pharesis.

4th Cycle of Chemotherapy (Consolidation chemo with CLASP) started on 23-12-02.

Ist leg : Inj Cytrabine 3.2 gm in 200 ml NS 12 hrly over 3hrs X4doses
Inj Leunase 6,400 I.U.deep 1/M on 2nd day after 4th dose of cytrabine.

2nd leg : Same as above starting on 30-12-02
Fever started from D12. Blood culture and Urine Culture grew E.Coli.
Given broad spectrum antibiotics including Vancomycin, Meropenem. Also given amphotericin (12 doses -25 mg each). Potassium supplementation as before. Inj Neupogen (G-CSF 150 mcg given for 22 days. Renal function normal but USG (Abd)- showed increased kidney size. Also received 5 units of platelet pharesis & 3 units of packed cells. ANC recovered to>500/mm3 on D30.

She developed Acute Fissure in Ano during this cycle-operated under GA on 5-2-03 (done Anal dilatation with fissurectomy with excision of skin tag).

Bone Marrow (5-2-03) : Myeloblasts 0% Promyelocytes 2% Myelocytes 9% Metamyelocytes 12% Neutrophils 6% Erythroid series 51%. Cellularity normal, ME: : 1:1:1.2. Erythyroid hyperplasia, predominantly late and intermediate normoblasts. Evidence of megaloblastic erythropoeisis. Myeloid series- No evidence of hyperlasia. Predominant cells are myelocytes & metamyelocytes. No increase in myeloblasts.

5th Cycle of Chemotherapy (Consolidation chemo with MACE) started on 10-2-03.

Inj Amsacrine 100mg in 500 ml of 5%Dex over 1hrsX5days(D1-5)
Inj Cytrabine 200mg in 500 ml of DNSX24hrs D1-5
Inj Etoposide 100mg in 200ml 5% Dext over 4 hrs D1-5.

Presented on D9 with mucositis GrII, fever. Given broad spectrum antibiotics Zosyn+ Targocid. Meropenem started on D18 in place of Zosyn, rest same. Inj Ambisome 50mg from D17 to D26.
Blood < C S Grew E.Coli Sensitive to Imipenem, piperacillin+Tazo,
27-2-03 Ceftriaxone, Genta, Ceftazidime, cefoperazone+sulbactam.

Urine< C S grew E.Coli
ANC recovered to >500/mm3 on D28
Received 4 units of platelet pharesis, 4 PRPs, 1 units of fresh blood, 3 packed cells.

6th Cycle of Chemotherapy (Consolidation chemo with Highdose Cytosine arabinoside) started on 2-4-03.

Inj Cytosine arabinoside 3gm/m2 (3.2gm) in 200ml NS 12hrly over 3 hrsX6doses (on days 1,2,3)

Presented with febrile neutropenia on 11th day. Which responded to broad spectrum antibiotics Zosyn +Amikacin+Targocid. Received 2 units Platelet Pharesis.
Blood < C S grew Staphylococcus aureus
Recovered by day 18th

BONE MARROW (Dt. 06/05/2003)

Microscopic Examination :

Results: Myeloblast 00, Promyelocytes 00, Myelocytes 10, Band 05, Neutropphils 10, Eosinophils 00, Basophils 00, Erythroid Series 50, Lymphocytes 16, Plasma Cells 00
Cellularity : Normal ME Ratio : 1.8:1
Erythroid Series : Shows evidence of hyperplasia. Predominant cells are late and intermediate normoblasts. No evidence of megaloblastic erythropousis.
Myeloid Series : No evidence of hyperplasia. Predominant cells are myelocytes and metamyelocytes. No increase in myeloblasts.
Megakarocytes : Normal
Other cells : No increase in cells of lymphocytic series. No lymphoma deposit seen. No increase in plasma cells.
Parasites : Not seen.
Opinion : Normocellular normoblastic marrow with erythroid hyperplasia

REVIEW BONE MARROW REPORTS

Pre-treatment Bone marrow (at diagnosis)

(14-09-2002)
BM 592/02 - marrow done at the time of diagnosis shows fragments of variable cellularity and a thick cellular smear. There is a marked erythroid hypoplasia. Most of the precursors seen are late normoblasts with mild dysplastic maturation. 73% of the nucleated cells in the marrow are myeloblasts (Type I and II with early pinking in part of the cytoplasm). Scattered Auer rods are seen. Many of the blasts have moderate amount of cytoplasm and the nuclei show significant dysplastic changes (irregular nuclear folding and lobulation) and prominent nucleoli. Some maturation towards neutrophils is seen. Dysplastic eosinophils are present. There is no monocytosis. Scattered megakaryocytes with dysplastic changes are seen. A random differential count on 200 cells is as follows :- Erythroid 4% Myeloblasts 73%, Myelocyte 1%, Band form 7.5%, Neutrophis 3.5%, Eosinophils 0.5%, Lymphocytes 10.5%.

IMPRESSION Consistent with AML - M2 with significant dysplastic features.

(12-10-2002)
BM 664/02 - marrow done after completion of induction chemotherapy shows hypocellular particles and smear. There is a marked erythroid hyperplasia with all stages of maturation seen. 14% of the nucleated cells are blasts some of which clearly show the original dysplastic morphology. Occasional Auer rods are seen. Maturation towards neutrophils is also evident. Scattered megakaryocytes with evidence of hyperlobulation and karyorrhexis are seen. Many smear cells and macrophages with cellular debris are seen. A random differential count on 200 cells is as follows :- Erythroid 64.5%, Blasts 14.5%, Myelocytes 3%, Band forms 1.5%, Neutrophils 4.5%, Lymphocytes 10.5%, Eosinophils 1.5%.

IMPRESSION Post induction marrow showing regenerating marrow with residual leukemic cell population (marrow not in remmision).

Patient remained in CR till 19th October 2004 (i.e for about 18 months from completion of Chemotherapy). She was asymptomatic till then when a routine haemogram showed some abnormalities.

Hb 12.2 gm/dl, TLC 3600 / cumm, DLC P28 L70 E1 M1, Platelets 32,000 / cumm

Bone marrow Aspiration : (19/10/2004)

Microscopic Examination    |    Results (%)    |    Normal Range(%)

BLAST                                             21                       0.2 - 1.5
PROMYELOCYTES                       05                       2.1 - 4.1
MYELOCYTES                                02                       8.2 - 15.7
METAMYELOCYTES                      01                       9.6 - 24.6
BAND                                               04                       9.5 - 15.3
NEUTROPHILS                              03                       6.2 - 12.0
EOSINOPHILS                                00                       1.2 - 5.3
BASOPHILS                                    00                        0.0 - 0.2
ERYTHROID SERIES                     49                       18.4 - 33.8
LYMPHOCYTES                              15                       11.1 - 23.2
PLASMA CELLS                              00                        0.4 - 3.9

CELLULARITY : NORMAL

ME Ratio : 1:1

ERYTHROID SERIES: Shows no evidence of hyperplasia. Predominant cells are late and intermediate normoblasts. No evidence of megaloblastic erythropoeisis

MYELOID SERIES : Evidence of hyperplasia. Predominant cells are myeloblasts.

MEGAKARYOCYTES : Reduced.

OTHER CELLS : No increase in cells of lymphocytic series. No lymphoma deposit seen. No increase in plasma cells. No increase in lymphoblasts.

PARASITES : Not seen.

OPINION : RELAPSE - IN A DIAGNOSED CASE OF AML.

CYTOGENETIC REPORT : Awaited

Sukriti's Bone Marrow Slides - Click below

• At Diagnosis
• After 1st Induction
• Relapse

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