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

11. 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

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

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

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

16. 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

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

18. Circulation. 2004;109:e146-e149 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)

19. 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 Onkologie. 2003 Aug;26(4):348-50 Haematologica 1997; 82:463-464

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

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