HEMATOLOGY QUIZ-CASE 1 403 CONTINUING MEDICAL EDUCATION ΣΥΝΕΧΙΖΟΜΕΝΗ ΙΑΤΡΙΚΗ ΕΚΠΑΙΔΕΥΣΗ Hematology Quiz-Case 6

Archives Of, Medicine
2008 unpublished
A 62-year-old man with acute myeloblastic leukemia (M2), who had completed his first cycle of consolidation chemo-therapy for his disease, was admitted to the hospital due to fever up to 38.6 o C and a left nasal congestion which was started 6 days before. The patient had been examined by an external otolaryngologist when the symptoms started and was treated with mometasone nasal spray, oral loratadine, and amoxacillin/ clavulinate without any improvement in his symptoms. His family history was
more » ... family history was unremarkable. The diagnosis of M2 AML was established 4 months before and the patient was treated with 2 courses of DAT chemotherapy (daunorubicin 50 mg/m 2 for D1, 3, 5; cytarabine 100 mg/m 2 , bd, for 10 days & thioguanine 100 mg/m 2 bd for 10 days) followed by one cycle of high dose cytarabine. A complete remission was achieved after the first cycle induction therapy and was continued after the second cycle of high dose cytarabine. After the first consolidation therapy the patient experienced a remarkable neutropenia which lasted for one month despite the use of sc G-CSF. The symptoms started 42 days after the first day of consolidation therapy. On physical examination the patient had a temperature of 38.2 o C, a pulse rate of 110/min and a blood pressure of 125/90 mmHg. There was also an extended red & brownish area in the skin of the left nasal region along with left nasal congestion. A complete blood count revealed mild leukopenia (3.1×10 9 /L) with severe lymphopenia (0.5×10 9 /L), anemia (Hb 10.9 g/dl, Ht 34%) and normal platelet counts. The basic blood chemistry was within normal limits, with the exception of increased liver enzymes (AST 52 U/L, ALT 64 U/L and γGT 73 U/L). Blood cultures were negative, while chest X-rays revealed no abnormalities. Due to the nasal symptoms a maxillofacial CT scan was performed and showed extensive left maxillary sinus disease. Soft tissue density was noted in the left maxillary sinus with higher density areas within. A widening of the left osteomeatal complex was also observed. The other paranasal sinuses were normal. The patient was given a combination antibiotic therapy (ceftazidime, gentamicin and teicoplanine) with no effect on fever and then on day 4 of admission amphotericin B was added to therapy. The fever was stopped 5 days after amphotericin B therapy but the red/brownish area of the left nasal area was enlarged. One week after, the patient underwent sinus surgery where a left antrostomy/uncinectomy and left maxillary sinus evacuation were performed. The contents in the maxillary sinus consisted of yellowish to greenish, inspissated mucoid material. Tissue specimens revealed inflammation with some tissue Figure 1
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