Dr. L.G.Aishwarya Lakshmi MD 2nd year

Prof. Dr. P. John SolomonDepartment of Paediatric Hematology

and OncologyGovernment Stanley Medical College

HISTORY Anand 6 yr Male Fever - 2 monthsOral ulcers - 2 monthsInvestigated & treated in Dharmapuri &

SalemNo records shownHistory unreliable

FINDINGS FebrileHealing oral ulcersNo lymphadenopathyNo pallorNo purpuraAbd: N, CVS: N, RS: N, CNS: N

DIFFERENTIAL DIAGNOSIS

HIVAplastic anemiaLeukemia

INVESTIGATIONS AT STANLEYHb: 11.1g/dLTC: 4400 cells/cummDC: Neutrophils-1% Band forms-4% Atypical lymphocytes-13% Lymphocytes-82%Platelets: 19000/cummPeripheral smear: thrombocytopenia, atypical

lymphocytes Urine- N, CXR- N, Mantoux- Neg, HIV-Neg

INVESTIGATIONS DONE IN PRIVATE HOSPITAL IN CHENNAI(BEFORE COMING TO STANLEY)Hb: 12.6g/dLTC: 4900 cells/cummDC: Blast cells-14% Polymorphs-5% Lymphocytes-80% Eosinophils-1% platelets -30000/cumm

INVESTIGATIONS- STANLEYHb: 11.1g/dLTC: 4400 cells/cummDC: Neutrophils-1% Band forms-4% Atypical lymphocytes-13% Lymphocytes-82%Platelets: 19000/cummPeripheral smear: thrombocytopenia, atypical

lymphocytes.

COUNTS AFTER 1 WEEK OF STEROIDHb: 4.6g/dLPlatelets: 2000/cummTC: 10500/cummDC: Blast cells - 64% Lymphocytes - 36%

BFM protocol : day 8 blasts <1000/µl : GR day 8 blasts >1000/µl : PR

HIGHLIGHTS

Absence of typical blast cells in peripheral blood does not rule out acute leukemia.

Steroids should not be used in undiagnosed fever.

PANCYTOPENIA

Splenomegaly No Splenomegaly

BM BM Abnormal Normal Abnormal Hypocellular

Acellular

An approach to differential diagnosis of pancytopenia Ref : Philip Lanzkowsky

•Leukemia•Storage diseases

• Lymphoma•Hypersplenism Granuloma TB, Sarcoid

•Leukemia

•Early aplastic anemia

•Aplastic anemia Congenital acquired: idiopathic secondary

ATYPICAL LYMPHOCYTES Some of the causes:1. Viral infections: Infectious mononucleosis, CMV,

Infectious hepatitis.2. Bacterial infections: Tuberculosis.3. Mycoplasma pneumonia.4. Protozoan infections: Malaria, Toxoplasmosis.5. SLE.6. Sarcoidosis. Atypical cells may also be seen in Leukemia

and lymphoma. Ref: Barbara J Bain.

ATYPICAL LYMPHOCYTE

LYMPHOBLASTS

NORMAL LYMPHOCYTES

IMPORTANT MESSAGE

Absence of typical blast cells in peripheral smear does not rule out acute leukemia.

Persistent pancytopenia : Bone Marrow Examination.

Undiagnosed fever - no steroids.Delay in diagnosis Morbidity & MortalityEarly referral.Most confirmatory test immediately.