Chief Complaint 백혈구 증가 onset : 내원 1 주 전 Present Illness 04 년 8 월 AML M4 진단. High dose Ara-C+ Idarubicine 항암치료 후 complete remission. Pneumonia 로 vetilator apply 하며 12 일간 ICU care 함. ‘08 년 1 월 말초혈액에서 immature cell 이 5% 보여 골수검사시행. Therapy related MDS 진단하여 Vidaza 사용 계획. ‘08 년 5 월 20 일 follow up 외래 검사결과 백혈구증가 보여 입원 방 O 희 F/58 Adm

Past medical history DM/HTN/Tbc/Hepatitis B (-/-/-/-) * 04 년 8 월 AML,M4 진단 → 05 년 2 월 28 일 molecular CR → 08 년 1 월 therapy related MDS 진단 Op Hx(+): appendectomy : 40 YA hemorrhoidectomy : 40 YA TAH and BSO : 26 YA Personal history Smoking (-) Alcohol (-)

Family history unremarkable 70 세 68 세 63 세 alcoholismCVA

General fatigue (+) febrile sense (-) weight loss (-) edema (+) night sweating (-) Skin rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) dizziness(-) Eye & ENT visual disturbance (-) nasal obstruction(-) Respiratory cough (-) sputum (-) tachypnea (-)

Cardiac chest pain (-) dyspnea on exertion (+) palpitation (-) orthopnea (-) Gastrointestinal A/N/V/D/C (+/-/-/-/-) melena (-) hematochezia (-) Urinary dysuria (-) frequency (-) urgency (-) RU sense (-) Musculoskeletal arthralgia (-) joint swelling (-) Neurologic syncope (-) seizure (-) dizziness (+)

Vital sign 120/80mmHg – 88/min – 20/min – 36.5°c General alert mentality chronically ill looking appearance performance status : ECOG 2 Skin single, papular erution with pustule formation at lip, conjunctiva vesicle formation at irritation site Head & Neck neck vein engorgement (-) cervical lymphadenopathy (-) Eye, Mouth & ENT isocoric pupil with PLR (++/++) white sclera pale conjunctiva gum hypertrophy (-) PI (-) PTH (-/-)

Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft and flat abdomen splenomegaly (-) hepatomegaly (-) normoactive bowel sound tenderness (-) rebound tenderness (-) no palpable mass no abdominal bruit Back & Extremities CVA tenderness (-/-) both leg non-pitting edema (+/+)

CBC 211,000/mm² -7.6 g/dl – 23.1%- 164k DC neutrophil segment : 4% lymphocyte : 5% monocyte : 3% blast: 88% nucleated RBC: 1% Coagulation test a PTT 36.1 sec PT 15.2 sec INR 1.18 PB smear hypochromic anisocytosis

Chemistry TB 0.26 mg/dL AST/ALT 22/11 IU/L ALP/GGT 49/64 IU/L Prot/Alb 6.9/3.5 g/dL BUN/Cr 17.7/0.36 mg/dL Ca/P/uric acid 7.7/2.6/5.7 mg/dL Na/K/Cl 135/6.0/102 mmol/L LD 1340 IU/L UA PH 6.5 SG Occult Blood (-) Protein (-) Glucose (-) RBC 0~1/HPF WBC 0~1/HPF

Normal Sinus Rhythm (HR 99/min)

#1. leukocytosis with immature cells #2. known therapy related MDS #3. known AML, CR state

# 1-3. AML relapse r/o Myelodysplastic syndrome leukemic transformation

#1. Bone marrow aspiration and biopsy morphologic study cytochemistry flow cytometry (marker study) cytogenetics (karyotyping, FISH) molecular study (RT-PCR) Serum chemistry, CBC Coagulation study (PT, aPTT, fibrinogen, D-dimer)

#1. Reverse isolation Placement of central venous access device (e.g Hickman catheter insertion) Hydration Transfusion Leukapheresis Induction Chemotherapy

BM report blast : 33.6 % AML, M BM report blast : 1.4% AML in remission BM report blast : 26 % treated AML, persistent BM report blast : 1.0% AML in remission BM report blast : 9.8% Therapy related MDS AI induction HD Ara-C ID induction HD Ara-C ID consolidation #1 (04/9/14~20) (04/10/18~22)(04/11/29~05/12/07) ICU care (05/1/31~2/11) vancomycin meropenem amphotericin B ganciclovir bactrim immunoglobulin Sputum: A.baumani (+) CMV antigenemia (+) …08.5

B PB : K blast 2%

BM aspiration X40

BM aspiration X1000

BM biopsy X100

* Chromosome: inv (16)(p13q22) AI induction (04/9/14~20) Cytarabine 150mg/day for 7 days Idarubicin 18mg/days for 3 days Leukemia marker CD 13(+) 90% CD33(+) 80% CD14(+) 90% HLA DR(+)

Harrison’s principles of Internal Medicine 17 th Edition

급성 백혈병의 세포 화학적 염색 양상 급성 백혈병의 세포 화학적 염색 양상 Acute LeukPeroxidase/SBBANBEPASAP ALL- -+/++-/+ AML, M0---- AML, M1+-+- AML, M AML, M3+++--/+++ AML, M4++++-/++++ AML, M AML, M AML, M *sudan black B /MPO..myeloperoxidase Alpha-naphtylbutyrate esterase

I. MANAGEMENT OF NEWLY DIAGNOSED ACUTE MYELOID LEUKEMIA A. Induction—Daunorubicin 45–60 mg/m 2 /day for 3 days (or idarubicin 10–12 mg/m 2 /day for 3 days) and cytarabine 200 mg/day for 7 days B. Postremission 1. Favorable risk—Cytarabine, 3 g/m 2 over 3 hours every 12 hours on days 1, 3, and 5 every month for 4 months 2. Intermediate risk—As for favorable risk; or, if HLA-matched sibling exists, allogeneic hematopoietic cell transplantation; or, if no matched sibling exists, two courses of cytarabine followed by autologous transplantation 3. Unfavorable risk—If HLA-matched related or unrelated donor is available, proceed to allogeneic transplantation; if not, treat as for intermediate risk [ TABLE ] COMMON REGIMENS FOR COMMON FORMS OF ACUTE LEUKEMIA (Cecil, 23th edition )

BM report blast : 33.6 % AML, M BM report blast : 1.4% AML in remission BM report blast : 26 % treated AML, persistent BM report blast : 1.0% AML in remission BM report blast : 9.8% Therapy related MDS AI induction HD Ara-C ID induction HD Ara-C ID consolidation #1 (04/9/14~20) (04/10/18~22)(04/11/29~05/12/07) ICU care (05/1/31~2/11) …08.5

* chromosome inv(16 )(p13q22) High dose Ara-C+ ID induction ( ~22) Cytarabine 3000mg/day for 5 days Idarubicin 15mg/days for 2 days

I. MANAGEMENT OF NEWLY DIAGNOSED ACUTE MYELOID LEUKEMIA A. Induction—Daunorubicin 45–60 mg/m 2 /day for 3 days (or idarubicin 10–12 mg/m 2 /day for 3 days) and cytarabine 200 mg/day for 7 days B. Postremission 1. Favorable risk—Cytarabine, 3 g/m 2 over 3 hours every 12 hours on days 1, 3, and 5 every month for 4 months 2. Intermediate risk—As for favorable risk; or, if HLA-matched sibling exists, allogeneic hematopoietic cell transplantation; or, if no matched sibling exists, two courses of cytarabine followed by autologous transplantation 3. Unfavorable risk—If HLA-matched related or unrelated donor is available, proceed to allogeneic transplantation; if not, treat as for intermediate risk [ TABLE ] COMMON REGIMENS FOR COMMON FORMS OF ACUTE LEUKEMIA (Cecil, 23th edition )

BM report blast : 33.6 % AML, M BM report blast : 1.4% AML in remission BM report blast : 26 % treated AML, persistent BM report blast : 1.0% AML in remission BM report blast : 9.8% Therapy related MDS AI induction HD Ara-C ID induction HD Ara-C ID consolidation #1 (04/9/14~20) (04/10/18~22)(04/11/29~05/12/07) ICU care (05/1/31~2/11) …08.5

* CBFB (+): 3.6% HD Ara-C +ID consolidation ( ~ ) Cytarabine 3000mg q 12hr at day 1,3,5,7,9 (for 5 days) Idarubicin 15mg/days at day 1-3 (for 3days)

BM report blast : 33.6 % AML, M BM report blast : 1.4% AML in remission BM report blast : 26 % treated AML, persistent BM report blast : 1.0% AML in remission BM report blast : 9.8% Therapy related MDS AI induction HD Ara-C ID induction HD Ara-C ID consolidation #1 (04/9/14~20) (04/10/18~22)(04/11/29~05/12/07) ICU care (05/1/31~2/11) …08.5

BM report blast : 33.6 % AML, M BM report blast : 1.4% AML in remission BM report blast : 26 % treated AML, persistent BM report blast : 1.0% AML in remission BM report blast : 9.8% Therapy related MDS AI induction HD Ara-C ID induction HD Ara-C ID consolidation #1 (04/9/14~20) (04/10/18~22)(04/11/29~05/12/07) ICU care (05/1/31~2/11) …08.5 vancomycin meropenem amphotericin B ganciclovir bactrim immunoglobulin Sputum: A.baumani (+) CMV antigenemia (+)

B PB : K blast 5%

Blast : 9.8% BM aspiration X40

BM biopsy X100

* chromosome del (7)(q22) Special stain PAS(-) MPO(-) ANBE(-)

B PB : K blast 74%

BM aspiration X40

BM aspiration X1000

BM biopsy X100

* Chromosome : DEL 7 (+), CBFB (-)

Inv 16CBFBDel

CD 13(+) CD33(+) CD14(+)(-) HLA DR(+) CD 19(-) CD10(-) CD34(+) : intermediate CD7(+) : intermediate CD117(+)

Acute myeloid leukemia, therapy related

LDH (U/L) AD induction Ara-C 300mg (200mg/BSA) * 7 days Daunorubicin 70mg (45mg/m2) * 3 days WBC (/mm3) 88% 87%88% 5% 26%43% 67% 80% 89% 92% 82% 87% 88%