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Abdominal pain in a 21 old lady


Abdominal pain in a 21 old lady


حالة سريرية

الوصف الكامل Background
A 21 year old female presents to A/E complaining of abdominal pain and nausea. Her symptoms started 2 months earlier but they are increasing. She described the pain as discomfort in epigastrium and left upper abdomen with no radiation. It's worse after eating and she can't eat well due to feeling full stomach. Recently she's easy fatiguable. No vomiting. No change in BM or stool colour. No fever. She tried OTC antispasmodics with no benefit. She's not using other medication. No hx of trauma on abdomen.
ROS: unremarkable
PMH: tonsillectomy age 6.
She doesn't smoke or drink alcohol. Not sexually active. Family hx unremarkable.
Physical exam: alert, conscious. Generally good
BP 110/60. Pulse 96/m. RR 16/m. Osat 100%. T 37.1
HEENT: pale, no jaundice
Chest and CVS normal
Abdomen: mild tenderness in LUQ. Splenomegaly reaching the umbilicus. Mild hepatomegaly. no detecatable ascites.
No skin changes or palpable lymphadenopathy.
كتابة حرة وطرح موضوع النقاش!
What investigations u would like to order?
Awaiting the results, What's ur differential diagnosis for the patient?
المرجع

real life

Ghufran's picture
by
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I'll order CBC +Diff
Reticulocyte count

kandy's picture
kandy
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Quote:
no palpable lymphadenopathy

also the mediastinum node?

kandy's picture
kandy
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I think in hemolytic immune disease

Quote:
no jaundice

dose that mean bilirubin is normal ?

kandy's picture
kandy
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your ddx list should be created based on the key findings in history and exam which are anemia and splenomegaly in this case.

CBC with diff, blood smear, INR/PT/PTT, basic metabolic profile, and LFTs should ordered first.

DDx range from benign hem disorder ( sphero, thalassemia, , AIH, ..) to hem malignancy ( leukemia, lymphoma,..), infectious diseases ( IM, histo, leishmania, ...), ? splenic vein thrombosis

imaging wise, she need abd/pelvis CT with oral/iv contrast (if her renal function is ok).

we may need to order further tests (bone marrow biopsy, flow cytometry, specific infectious lab test...) based on the pending tests results.

Al Durra's picture
Al Durra
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Quote:
your ddx list should be created based on the key findings in history and exam which are anemia and splenomegaly in this case

Yea, this is whay I want 2 emphasize… anyone of us could have seen this patient when she presents for the first time.. u should make problem list and intial ddx to know what tests u want..
The PE showed splenomegaly which can explain her symptoms (abdominal discomfort, early satiety) and that occurred especially if the splenomegaly is recent and large. Her fatigue can be explained by her apparent anemia…
So our current problem list is splenomegaly, anemia… ddx can include:
- hemolysis (acquired like AIHA, PNH, Pernicious anemia…. Or congenital e.g. Thalassemia, spherocytosis..)
- Malignancy: Lymphomas, Leukemias (CML, CLL, some forms of acute leukemias, Hairy cell L), myeloid metaplasia/myelofibrosis, metastatic tumor….)
- Infections: (endocarditis, splenic abscess, Mononucleosis and other viral infx, Parasites..)
- Chronic liver disease
- Vascular causes (splenic vein thrombosis, portal vein thrombosis..)
- Infiltrative (Sarcoidosis, Amyloidosis
- Autoimmune diseases (e.g SLE
- Congenital metabolic diseases (Gaucher's

Quote:
dose that mean bilirubin is normal

No jaundice means no jaundice I see. bilirubin can be high but less than the level of causing clinical discoloration (around 3.5)

Quote:
also the mediastinum node

U mean palpation of that node clinically!!?
------------------------------
Let's see the initial tests:
WBC 110,000/microL
N 85%, L10%
Hb 9
MCV 78
Plt 500,000
Retic 3%
TB 1.1
ALT 30
AST 29
Alb 4
INR 1
ALP100
LDH 500
BUN 10
Cr 0.7
Uric acid 8.2
USS abdomen: homogeneous splenomegaly with great diameter of 22cm, Mild hepatomegaly 13cm with no focal lesions, no ascites, no apparent lymph nodes. Other structures look clear.
Peripheral blood smear pending
What do u think now??

Ghufran's picture
Ghufran
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I think it's CML (anemia & splenomegaly & elevation in WBCs most of them are neutrophils). The LAP should be low and we should detect Philadelphia chromosome Rolling Eyes
Dr.TH's picture
Dr.TH

oops .. she is just 21 .. the age is not appropriate for CML هممم
Dr.TH's picture
Dr.TH


hmmm, her age goes more with AML but her CBC /diff findings correlates more with CML/myelofibrosis. The absence of fever makes infectious etiology less likely.

CML typically presents during the 6th decade of age, although it can present at any age including childhood.

I do not know what the smear showed but I have a feeling that we may need a bone marrow biopsy.

Al Durra's picture
Al Durra
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As already mentioned, AML or CML are high on da list.
Peripheral smear would tell us if there's any Blasts
Would get a FISH (for pliladilphia) and Jak2 as well.
Quote:
The LAP should be low

True , but the test is not used anymore (today I was told that )

mbs2380's picture
mbs2380
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Blood film: WBC: markedly full of granulocytes with variable stages of maturation seen. Majority of them are myelocytes, metamyelocytes and bands. 5% promeylocytes and 2% blasts.
RBC: moderately decreased in number, normocytic
Platelets: normal shape, looks slightly high
This is typical for CML. although the age not typical.
Quote:
CML typically presents during the 6th decade of age, although it can present at any age including childhood

Later bone marrow studies and cytogenetics confirm Ph Positive CML Chronic phase
I was sorry 4 her having this disease in early age but still better than acute leukemias
Gleevec was the suggestive treatment but it was not available in the hospital. the hematologists were afraid of developng leukostasis due to hyperleukocytosis, so they advice to give her Hydroxyurea temporarily....
there's no clear guidelines to give that to asymptomatic patients in CML because risk of that complication is very low in the chronic phase of CML..
Anyway her WBC decrease dramatically with that treatment. later she was started on Imatinib and was to follow regularly the Hem/Onc clinic

Ghufran's picture
Ghufran
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Quote:
اقتباس:
The LAP should be low

True , but the test is not used anymore (today I was told that )

yea, it's an old test but still u read it in books and on exam questions.. it takes long time to do. they prep the smear then stain it, wait a time then count the score.. it's replaced now by cytogentics and ph chromosome detection which is more accurate in making the dx.
LAP score as well maybe low in other diseases so it's not specific for CML. e.g. can be low in PNH, some cases of meylofibrosis, hypophosphatasia..
Ghufran's picture
Ghufran
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but if leukemoid reaction is on the DD list shouldn't we do it Rolling Eyes ?
thanx for the info about age and LAP score
Dr.TH's picture
Dr.TH

Quote:
but if leukemoid reaction is on the DD list shouldn't we do it

Leukemoid reaction is one of the most important ddx for CML:
Leukemoid reactions which happens in response to severe infections or sometimes malignancy may give a picture similar of CML in blood film and bone marrow, and even the clinical picture can be unclear…
LAP score as u said is mentioned as a differentiating way between them but it doesn't give definitive result coz it can be near normal in 10% of CML pts and as well in CML+infection…. The definitive way is cytogenetics (ph chromosome)…
This is a nice article if u r interested: http://www.ejinme.com/article/S0953-6205(06)00163-4/fulltext

Ghufran's picture
Ghufran
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Quote:
but if leukemoid reaction is on the DD list shouldn't we do it Rolling Eyes ?
thanx for the info about age and LAP score

That's specifically what happened.
We had a 75 yr old pt with who had a hip fracture s/p surgery and we were consulter for her 41 000 WBC.
Whwat you can do in this situation is the following:
Look at her baseline WBC (like on presentation and may before her presentation as an outpatient recently) and in our patient the WBC were 8 on presentation. Because with a normal white count on presentation the myeloprilifrative disorders are unlikely because if the white count in such dosorders don't rise up over one night.
And of course u should look at the other things in the history like any recent symptoms that are suggestive of malignancy and look at the things that might have caused this leukamoid reaction ;infection,surgery;etc.
The differential is helpful , because in CML the basophil might increase as well and you might see some eblasts as well
Genereally for our pt we recommended just follow up and we would consider testing for JAK2 and philadilphia chromosome if the count didn't go down.

mbs2380's picture
mbs2380
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Ghufran, the link is broken? Rolling Eyes
pearls-3's picture
pearls-3
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http://www.ejinme.com/article/S0953-6205(06)00163-4/fulltext

mbs2380's picture
mbs2380
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the page will open if you copy the whole link Eye-wink
thanx doctors Eye-wink
Dr.TH's picture
Dr.TH

Thank y'all.
pearls-3's picture
pearls-3
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