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CASE PRESENTATION

CASE PRESENTATION. Dr. Mario Melgar Guatemala. THE PATIENT. MDM Age: 11 years old Origin: Guatemala city. History of Disease. Dysphagia 3 weeks, treated with anti-inflammatories CBC: Hyper leukocytosis Transfer to UNOP. July 8, 2008 Diagnosis: AML M4 245,000 WBC

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CASE PRESENTATION

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  1. CASE PRESENTATION Dr. Mario Melgar Guatemala

  2. THE PATIENT • MDM • Age: 11 years old • Origin: Guatemala city

  3. History of Disease • Dysphagia 3 weeks, treated with anti-inflammatories • CBC: Hyper leukocytosis • Transfer to UNOP

  4. July 8, 2008 • Diagnosis: AML M4 • 245,000 WBC • CSF negative, Thorax negative • Fever, oral lesions • Ceftazidime, Fluconazole • July 10, 2008 • Hypo tension • ICU • Vancomycin

  5. July 12 • Start on chemotherapy protocol (ADE) • G-CSF

  6. July 16 • Acyclovir • July 21 • Withdraw Vancomycin • Diarrhea • Neutropenia

  7. July 22 • Septic shock • Meropenem • Amikacyn • Amphotericyn B • July 24 • Vancomycin re started

  8. July 26 • Improvement in clinical condition • Out of ICU • July 29 • Amphoterecyn B withdraw • July 30 • TNC 310

  9. August 1 • TNC 1780 • Withdraw atbs – 4 hours later fever • Cultures • Cardiomegaly in X-rays

  10. Look back pericardial effusion • July 11 small pericardial effusion 8mm • July 16 pericardial effusion 10mm • New echocardiogram • August 4 pericardial effusion 15mm, septated • August 5 • Pericardial drainage and biopsy • 100 cc serohematic • 117 WBC (76% Lymph, 24% PMN) • Stains and cultures negative

  11. August 7 • Chest CT • Basal consolidation in both lungs • Needle biopsy – not enough material

  12. Pericardial biopsy • In some miocytes and histiocytes presence of eosinophylic nuclear inclusions sugesting CMV infection

  13. PERICARDIAL EFFUSION • CMV infection? • Other virus? • Neoplasic infiltration? • Drug toxicity?

  14. CMV pericarditis • Frasca 1980 • Review of viral serositis and pericarditis • Of 47, 5 influenza viruses, 1 parainfluenza, 1 coxsackie, 1 RSV, 3 mumps virus,, 1 adenovirus, 5 CMV • Saatsi 1993 • Case report of CMV pericarditis • Renal transplant recipient • Campbell, 1995 • 57 pericardial effussions in adults • 3 culture proven, 1 serological CMV • 1 infant with congenital hearth disease Boll Ist Sieroter Milan. 1980 May 31;59(2):112-20 Int Urol Nephrol. 1993;25(6):617-9. Links Am J Med Sci. 1995 Apr;309(4):229-34

  15. Other viruses • Daibata 1997 • 47 yo man, AML • Pericarditis due to HHV 6 • Aoyama 2004 • 31 yo woman, AML • Pericarditis • EBV reactivation Leuk Lymphoma. 2004 Feb;45(2):393-5 Leukemia. 1997 Jun;11(6):882-5.

  16. Infiltration • Wong, 2004 • 47 years, • Constrictive pericarditis • Etiology: tumor infiltration • Da Costa, 1999 • 2 year old AML • Cardiac tamponade at presentation with hyper leukocytosis Medical and Pediatric Oncology 32:120–123 (1999) Circulation. 2004;109:e146-e149

  17. Drugs • Galer,2003 • Patient with acute mielomonoblastic leukemia • Pericarditis due to Cytarabine • Larrea, 1997 • Case report • ATRA syndrome • Cardiac tamponade, treatment with steroids and pericardiocentesis Haematologica 1997; 82:463-464 Onkologie. 2003 Aug;26(4):348-50

  18. In our patient • Probably tumor infiltration • August 7 • Started chemo • Fever stopped • Good clinical evolution • New CT pending for assessment of lung consolidations

  19. Comments…

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