Skenario C

Mr AA, a 17 years old man, came to the clinic because of gum bleeding since 2 days
ago.He also complained of a persistent sore throat for the past 2 eeks. He recently
completed a eek course of antibiotic ithout a change in symptoms. He noticed
progressi!e malaise o!er the past 2 eeks, high fe!er associated ith night seating and
easily bruised. Since to days ago his gum had bled hene!er he brushed his teeth.
Physical examination" #$ 1%%&7% mm Hg, temperature '(.) * C. +o abnormality as
found in auscultation of lungs. H, 12%-&m ith regular rate, no abnormal heart sound.
Abdomen as soft, no tenderness, li!er as not palpable and the spleen as enlarged
.Schuffner ///0. 1here ere multiple petechie in palatal and ankles, cer!ical and
supracla!icular lymphadenopathy.
Laboratory results" Hemoglobin 7.2 mg&dl, #S, " (2 mm&h, platelets 2%%%%&mm', hite
blood cells 23%%%&mm'. #lood smear " blast cells ere found
Additional information
#one marro re!ealed lymphoblast .'(40 ith scan cytoplasm, no e!idence of a5urophyl
granules, no auer rods.
Questions:
1. 6hat do you think about this man suffered from7
2. 6hat is differential diagnosis of this case 7
'. Ho do you manage this pts 7
3. Ho is the prognosis of this case 7
2. hat is the complication of this case 7
Learning objective:
1he students ill be able to"
1. 8-plain the possible cause of high fe!er and bleeding in the pts
2. 8-plain the possible cause of night seating in this pts
'. 8-plain the differential diagnosis based on the abo!e data
3. $lan further laboratory e-amination
2. 9iagnose the disease
:. Manage the patient
Term Clarification
High fe!er
Sore throat
Malaise
+ight seating
$etechiae
Adenopathy
;um bleeding
Problem Identification
High fe!er
$ersistent sore throat
$rogressi!e malaise since 2 eeks
<ne eek antibiotic ithout symptom impro!ement
Multiple petehiae in palatal and ankles
;um bleeding since 2 days ago
All symptom occured in 2 eeks periods
Problem analysis
1. /s there any correlation of persistent sore throat and diagnosis7
2. 6hy did this patients more susceptible to infection7
'. 6hat as the causes of petehiae and gum bleeding in this patients7
3. 6hat is the mechanism of anemia, thrombocytopenia and leucocytosis in this
patients7
2. 6hy did the patient symptoms not relie!e ith antibiotic7
:. 6hat is the differential diagnosis of this patients7
7. 6hat is the most probable diagnosis7
(. 6hat as the prognosis of this case7
). 6hat as the complication of this case7
Hyothesis
!r AA" #$ years old had been suffering from acute lymhoblastic leu%emia&
'ynthesis
1. 1here is no direct relationship beteen sore throat and diagnosis.

2. 1his patients susceptible to infection becaused of leukocyte dysfunction.
'. $etechiae and mucocutan .gum0 bleeding is typical bleeding caused by
thrombocytopenia.
3. Anemia, thrombocytopenia and leucocytosis as a symptom of hematopoetic failure in
this patient caused by bone marro infiltration by malignant .blast0 cells.
2. /nfection in this patients as difficult to treat becaused of disturbance of cellular
immune mechanism. /n this case sore throat persisted e!en after a eek of antibiotic
treatment.
:. $etechiae, gum bleeding due to thrombocytopenia
Splenomegaly due to e-tramedullary hematopoesis
1achycardia ith regular rate and rhythm due to anemia and fe!er
C#C shon marro failure
99&
Acute =ymphoblastic =eukemia
Hodgkin>s =ymphoma
+on Hodgkin>s lymphoma
1hrombotic thrombocytopenic purpura
/mmune thrombocytopenic purpura
9rug induced thrombocytopenia

Acute =ymphoblastic =eukemia
Prognosis
prognosis" depend on treatment response and cost
ad !itam bonam, ad functionam dubia ad bonam
comlication
bleeding
sepsis