Problem 47 Fatigue and bruising in a teenager

The following investigations become available.

Investigation 47.1 Summary of results

Blood film (Figure 47.1) comment:

Figure 47.1

Macrocytic anaemia. Anisocytosis and poikilocytosis. Abnormal lymphoctes present; possibly atypical, possibly blasts.

Infectious mononucleosis screen (IM): Negative. EBV IgM: Negative.

While awaiting transfer to the haematology ward, he develops rigors and is noted to have a temperature of 39°C.

An urgent bone marrow aspirate is performed (Figure 47.2). Microscopic examination of the aspirate smears shows over 90% blasts, immature chromatin, few nucleoli, scant cytoplasm and few granules. Immunophenotyping of the bone marrow aspirate shows the presence of a lymphoblast populations staining for CD45, CD5, CD7, and cytoplasmic CD3, but negative for cell surface CD3, negative for the B lymphoid markers CD19 and CD79a, and negative for the granulocytic markers CD13 and CD33.

Figure 47.2

Immunophenotyping of peripheral blood yields similar results. Subsequent examination of bone marrow trephine sections shows complete replacement with a homogeneous infiltrate of lymphoblasts.

While the patient awaits further investigations, including a lumbar puncture, and prepares for initial treatment, the ward nursing staff are concerned that the he has become short of breath, with a dry cough and difficulty swallowing. You are asked to review him urgently.

He is sitting on the edge of his bed with respiratory rate of 25, a peripheral oxygen saturation of 94% on air and mild facial swelling. Chest examination reveals dullness to percussion at the right lung field base, with reduced breath sounds on the right side. You repeat the chest X-ray (Figure 47.3).

Figure 47.3

Soon after commencing chemotherapy the patient becomes confused and is noted to have reduced urine output.

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