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Patients Profile

15 year old male


c/c: Cervical Lymphadenopathies
fever, loss of appetite, productive cough with whitish sputum

Consult was done at the barangay health clinic he was given anti-tussive and Paracetamol

Claims to have TB exposure


High school student

PE:
Oriented but in CP distress
VS: BP 90/60; CR 85; RR 18
Skin: No pallor, warm to touch with good skin turgor
HEENT: pale palpebral conjunctiva, distended neck veins, CLAD, bilateral
Lung: Symmetrical chest wall expansion, clear breath sounds
Hear: normal rate with normal rhythm, no murmurs
Extremities: cold clammy extremities and capillary refill > 2 seconds

CBC
Test Result Interpretation
Hgb 99 Decreased anemia
Hct 0.30 Decreased anemia
WBC 110 x 10^9 Increased leukocytosis
Neutrophil 10 Decreased neutropenia
Lymphocyte 38 Normal
Eosinophil 0 Normal
Monocyte 2 Normal
Blasts 50 Abnormal finding
Platelet 140 x 10^9 Slightly Decreased

1. What is your initial impression?


Lower Respiratory Tract Infection to consider Pulmonary Tuberculosis associated with
Leukemia rule out Lymphoma

2. What other clinical findings or data you want to elicit from your patient to support your
clinical impression?
LRTI t/c PTB
o Duration of the cough
o Hemoptysis or coughing up of blood
o Unintentional weight loss
o Night sweats and chills
o Smoking history
Leukemia
o Enlarged liver or spleen
o Easy bruising or bleeding
o Recurrent nosebleeds
o Other infections other than what the patient recently is having

What are your differential diagnoses?


o Community acquired pneumonia
Signs of lobar or atypical pneumonia including crackles and dyspnoea.
Generally, shorter duration of symptoms compared with TB. If there is doubt,
one should consider treating for bacterial pneumonia first (without using
fluoroquinolones or other antibiotics with significant anti-tuberculous
activity) and assess for response.
o Lung Cancer
TB and lung cancer may co-exist; malignancy may erode granulomas.
Despite acid-fast bacilli (AFB) in sputum, if features suggest cancer (e.g.,
irregular cavities) or lung abnormalities progress in patients on anti-
tuberculous treatment, further evaluation for cancer should be pursued.
o Non-tuberculosis mycobacteria
Mycobacterium avium complex and M kansasii may both present as cavitary
lesions. Patient risk factors for TB may point to most likely diagnosis.
o Lymphblastic lymphoma
Differentiation between acute lymphatic leukemia and lymphoblastic
lymphoma with bone marrow infiltration is difficult and may be somewhat
artificial. There is evidence to support that the malignant cell population is of
the same type, but that the disease primarily starts in lymph nodes or bone
marrow.
o Since we are considering leukemia in our case as evidenced by a number of blast in
the CBC result and a markedly increase in the WCB count of the patient. Therefore,
we are considering these two conditions
Acute myeloid leukemia
Acute lymphoblastic leukemia
3. What laboratory tests you want to request?
o Mantoux Test
To confirm the exposure to tuberculosis
o Chest X-ray
To determine the presence of white spots or any infiltrates in your lungs
o Acid fast Bacilli smear and culture
An AFB smear is used as a rapid test to detect mycobacteria that may be
causing an infection such as tuberculosis. The sample is spread thinly onto a
glass slide, treated with a special stain, and examined under a microscope for
"acid-fast" bacteria. This is a relatively quick way to determine if an infection
may be due to one of the mycobacteria, such as M. tuberculosis. AFB smears
can provide presumptive results within a few hours and are valuable in
helping to make decisions about treatment while culture results are pending.
However, this rapid test is less sensitive than culture to diagnosis a
mycobacterial infection.
AFB cultures are used to diagnose active M. tuberculosis infections,
infections due to nontuberculous mycobacteria, or to determine whether TB-
like symptoms are due to another cause. They are used to help determine
whether the TB is confined to the lungs (pulmonary disease) or has spread to
organs outside the lungs (extrapulmonary disease). AFB cultures can also be
used to monitor the effectiveness of treatment and can help determine when a
person is no longer infectious.
o Sputum cytology
It is done to find out whether the condition merits a malignancy as a
diagnosis or noncancerous lung conditions such as pneumonia or
inflammatory disease, tuberculosis, or the buildup of substances in the lungs
like asbestosis.

o Peripheral blood smear


Review of the peripheral blood smear confirms the findings from the CBC
count. Circulating blasts are usually seen. Schistocytes are occasionally seen
if DIC is present.

o Flow Cytometry
Flow cytometry (immunophenotyping) can be used to help distinguish AML
from acute lymphocytic leukemia (ALL) and further classify the subtype of
AML (see the table below). The immunophenotype correlates with prognosis
in some instances.
o Blood chemistry profile
Most patients with AML have an elevated lactate dehydrogenase (LDH) level
and, frequently, an elevated uric acid level. Liver function tests and blood
urea nitrogen (BUN)/creatinine tests are necessary before the initiation of
therapy. Elevation of those test results, in a patient with an elevated WBC
(>25 109/L), indicate possible tumor lysis syndrome, and treatment should
be started immediately.
o Cytochemical stains
Cytochemical stains are an important adjunct to identifying and confirming a
myelocytic leukemia. Blood cells contain various enzymes, fats, and other
substances that can be identified by cytochemical means.
o Fluorescence in situ hybridization (FISH) is a test performed on your blood or bone
marrow cells to detect chromosome changes (cytogenetic analysis) in blood cancer
cells. FISH helps identify genetic abnormalities that may not be evident with an
examination of cells under a microscope.
o Biopsy of lymph node
Check the cause of enlarged lymph nodes that do not return to normal size on
their own.
Check the cause of symptoms, such as an ongoing fever, night sweats, or
weight loss.
Check to see if a known cancer has spread to the lymph nodes. This is called
staging and is done to plan cancer treatment.
Remove cancer.
4. Do your CPC
5. What is your final diagnosis?

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