1. Case conference
IM R3 박미나

2. 최o남(F/66) ADM
C.C: easy bruising
P.I: 3년전 고혈압 진단 후 약물 복용하고 있는 것 외 특이
병력 없었으나. 약 2주 전부터 왼쪽 손에 점상 출혈
(petechia) 발생하였으며, 이후 하지와 복부에 동일
병변 발생하여 외부 개인 병원 방문하여 혈액 검사 결과
혈소판 감소 소견 보여 자세한 검사 위해 내원
PMHx: DM/HTN/Tbc/hepatitis(-/+/-/-) Norvasc 5mg qd
op Hx (-)
FHx: none, PHx: alcohol(-) smoking(-)

3. Review of system weight loss(-), fever sense(-), chill(-), fatigue(+)
sweating(-)
rash(-), itching(-),
multiple petechia and purpura(+)
headache(-), gum bleeding(-), sore throat(-)
cough(-), sputum(-), hemoptysis(-)
chest pain(-), palpitation(+), edema(-),
chest discomfort(+)
A/N/V/D/C(-/-/-/-/-) , jaundice(-), melena(-)
frequency(-), dysuria(-), hematuria(-)
dizziness(-), tremor(-), syncope(-)

4. Physical examination 120/70mmHg -96회/min-20회/min-36.3°C
Alert mentality, chronic ill appearence
Multiple petechia and purpura on both extremity and abdomen
Pale conjunctiva, clear sclera
No neck vein engorgement, no cervical LN enlargement
CBS without crackle, RHB without murmur
soft and flat abdomen, no hepatosplenomegaly
no abdominal T/RT, normoactive bowel sound
No pph pitting edema, no CVA tenderness

5. Laboratory finding CBC/DC 2490/mm3 -10.2 g/dl –30.5 % -22K/mm3
(seg: 40%, lympho 52%, mono 7%)
( reticulocyte 1.29%, MCV fl, MCH 32.4pg)
PTT 40C33, PT INR 1.20
Chemistry
T/D bil /0.1mg/dL AST/ALT 25/23 U/L
T-prot/Alb 6.2/3.5g/dL ALP/rGT 55/26 U/L
BUN/Cr /0.7mg/dL Na/K/Cl 136/3.9/101 mEq/L
Glucose mg/dL LD/CK /104U/L
Ca /Mg /P /uric acid 9.1/2.7/2.3/0.9 mg/dL
TIBC /iron 209 / 58 ug/dL, Fol 7.2ng/mL ,Fer 64ng/mL
LAP score 198

6. Chest X-ray

7. Impression Plan Myelodysplastic syndrome r/o aplastic anemia
r/o acute leukemia
r/o idiopathic thrombocytopenic purpura
Plan
Abdominal sonography
Bone marrow aspiration and biopsy
Autoimmune marker, viral marker
Antiplatelet antibody

8. Abdominal sono

9. Chromosome study with BM: 46XX(35)
Bone marrow exam ( ) CBC/DC /mm g/dl –30.8 % -21K/mm3 (seg: 40%) Blast : 15.2% , cellularity : 60% => Myelodysplastic syndrome refractory anemia with excess blast II, C/W
Chromosome study with BM: 46XX(35)

10. 날짜
WBC(mm3)
Hgb(g/dl)
PLT(mm3)
Dfferential count
6/24
2490
10.2
22K
Seg40%,lymph52%,mono7%
7/1
2150
16K
Seg42%,lymph47%,blast1%
7/15
2690
10.3
19K
Seg37%,lymph54%,blast2%
7/26
2650
10.6
14K
Seg36%,lymph56%,blast1%
8/11
3150
10.1 7K
Seg30%,lymph59%,blast5%

11. Bone marrow exam (2005. 8. 12) CBC/DC 2360/mm3 -9
Bone marrow exam ( ) CBC/DC /mm g/dl -77K/mm3 (seg: 40%,blast: 8%) Blast : 21.0% , cellularity : 60% => Acute myelogenous leukemia(FAB M2), most probably
FISH with BM : AML1/ETO rearrangement (-)
PCR : AML1/ETO rearrangement (-)
Chromosome study with BM: 46XX t(2:4)(p23:q35)(5)
/46XX(15)

12. Plan: chemotherapy Diagnosis: Acute myelogenous leukemia(M2)
Intermediate risk group
Plan: chemotherapy
(Induction+consolidation#3)
=> AI induction for AML ( )
Ara-C 150mg(D1-7)+ Idarubicin 15mg(D1-3)

13. Clinical course 날짜 WBC(mm3) Hgb(g/dl) PLT(mm3) D/C GCSF 8/18(D1) 3000
9.3
67K
Seg55%
8/24(D7)
330
9.8
30K
Seg34% ↑
8/29(D11)
250
8.7
24K
Seg9.2%
9/2(D16)
500
10.7
39K
Seg4%
9/9(D23)
620
7.4
61K
Seg42%
9/10(D24)
1580
9.7
21K
Seg50%
9/12(D26)
2850
15K
Seg74%
9/14(D28)
1610
8.9
13K
Seg68%

14. piperacillin+tazobactam D18 + amphotericin D21 hickman catheter remove
D D16 +vancomycin
piperacillin+tazobactam
D18
+ amphotericin
D21 hickman catheter remove
D16 periodontitis
D18 blood culture: candida albicans

16. Chromosome study with BM: 46XX(35)
Bone marrow exam ( ) CBC/DC /mm g/dl -13K/mm3 (seg: 69%) Blast : 0.2% , cellularity : 30% => Acute myelogenous leukemia(FAB M2), most probably
Chromosome study with BM: 46XX(35)

18. FAB morphologic guideline for MDS (1982)
: heterogenous, various cytogenic abnormality,
widely variable clinical outcome
WHO classification of MDS (2001)
Lowering threshold for defining AML from 30%->20% blasts in BM, pph blood
Division of low grade categories of RA and RARS into 5 entities
Subdividing RAEB into two categories depending on number of
blasts in blood and marrow
Removing CMML from MDS category into myelodysplastic/
myeloproliferative disease
<Elimination of FAB caterogy of RAEBT>
FAB category of RAEBT = WHO category of MDS related AML
(clinical, biologic, genetic, prognosis)

20. MDS : hematologic, pathologic, and biological heterogeneity
Expectation for survival and leukemia evolution
-> reflect natural Hx
-> therapeutic and management decisions
The International Prognostic Scoring System (IPSS)
: BM blast pecentage, cytogenetic pattern,
number of cytopenia

24. MDS Secondary leukemia Primary curative Tx for MDS =>allogeneic SCT
MDS with RA and RARS => lower relapse rate,
>50% long term disease free survival
MDS with RAEB => less favorable, higher relapse risk
Secondary leukemia
< ys old: standard induction therapy
=>intensive post-remission therapy (including BMT)
=>overall outcome is inferior to primary MDS/AML
> ys old
reasonable performance status=>standard induction therapy
=> supportive care only (median survival 3-4months)