A 65 Year Old Man With Pancytopenia

A 65 year old man is referred to a hematology-oncology center for evaluation of his pancytopenia. The patient has a history of constant fatigue over the last 1 month, he feels short of breath on mild exertion and had a persistent upper respiratory infection for the past 2 months with chest congestion and a non productive cough. He has also noticed that he has developed multiple bruises from minor trauma on his legs or arms. He denies any similar symptoms in the past and has not used any new medicines recently.

Physical Examination:

• Patient looks pale.
• petechiae around his mucosal surfaces
• No lymphadenopathy
• Mild ronchi on auscultation of the lungs
• soft systolic murmur on auscultation of heart.
• Abdomen is soft and non tender with a palpable spleen
• Normal neurological examination.

The routine blood test done by his general physcian shows a pancytopenia and the valuse are shown below:

Hb = 11.5gm/dl, WBC = 3100/mm3, Platelet = 128,000/mm3

What is the Differential Diagnosis?

• Aplastic anemia
• Acute myelogenous leukemia
• Acute lymphocytic leukemia
• Lymphoma
• HIV
• Hairy cell leukemia
• Chronic myelogenous/ lymphocytic leukemia

On further work up the blood smear had the following picture;

several large myeloblastic leukocytes , some with Auer rods and notched(bilobed) nuclei

HIV Elisa was negative 

Bone marrow biopsy shows high proportion of blast staining with myeloperoxidase.

What is the Final Diagnosis?

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.

Acute Myelogenous Leukemia:

Case Discussion:

Acute myelogenous leukemia (AML) is a hematopoietic malignancy characterized by the over proliferation of myeloid cells in bone marrow. 

It can occur at any age but the prevalence increases with age. 

Clinical features: Patients usually present with:

• Fatigue
• Easy bruising
• Dyspnea
• frequent infections
• Arthralgias

On Examiantion one may find:

• Fever
• pallor
• hepatosplenomegaly 
• petechiae
• mucosal bleeding
• ocular hemorrhages

Diagnosis: On Workup following are seen:

• Decreases hemoglobin, WBC count and platelets
• Blood smear shows large myeloblasts with notched nuclei and Auer rods
• Bone marrow biopsy shows numerous blasts of a myeloid origin that stain with myeloperoxidase.

Treatment: Chemotherapy helps about 50% of patients go into remission but relapse is common and the prognosis is poor.