Self-evaluation Tutorial 2009
Prof Dr Irene Lorand-Metze
State University of Campinas
SEV 3.2
start
Male 34 years old patient. He came to the
Emergency Unit of our Hospital referring high
fever and cough for 3 days. Sputum was
greenish.
The patient suffered from schizophrenia and was
using clozapine.
Physical examination: he was in a bad physical
condition. Blood pressure: 105 x 75 mmHg.
Heart frequency: 98 beats/min
Cefalexine had been instituted.
Peripheral blood counts
• Hb : 11.1 g/dl
• MCV: 85 fl
• MCH: 28 pg
• Platelets: 133 x 109 /l
• Leukocytes: 0.3 x 109 /l neutrophils: 0.1 x 109 /l
Avaliação clínica inicial
• Dados clínicos sugerem pneunonia lobar
• Hemograma: a série mais afetada é a
granulocítica
• Hb e plaq. Excluem aplasia e leucemia aguda
• Até agora parece uma agranulocitose
• Nos antecedentes, tem medicação que pode dar
agranulocitose (clozapina)
Question 1
•
According to the clinical data and the peripheral blood
counts, which is the most probable diagnosis?
1.
Agranulocytosis due to psychotropic agents and
infection
2.
Acute leukemia and pneumonia
3.
Aplastic anemia and pneumonia
4.
Myelodysplastic syndrome and infection
5.
Fanconi’s anemia and septicemia
Question 2
•
Which laboratory tests should be collected
immediately?
1.
2.
3.
4.
5.
Chest radiography
Bone marrow cytology and cytogenetics
Investigation of PNH
Bone marrow cytology and chest radiography
Bone marrow histology and DEB test
Confirmar a pneumonia
neutropenia → mielograma
Question 3 - introduction
• The chest radiography revealed a pneumonia of
the inferior lobe of the left lung.
• BM cytology showed: Granulocytic series with
blasts and promyelocytes: 11% (Fig 1);
erythroblasts: 58% (Fig 2); lymphocytes: 28%;
megakaryocytes +++ (Fig 2)
Bone marrow cytology
Diagnóstico final
• Agranulocitose (por clozapina) e pneumonia
lobar
• Para causas, ainda excluir:
• SMD → cariótipo
• HPN → pesquisa de deficiência de proteínas
ancoradas GPI (CD55, CD59, CD66b, CD14)
• Anemia de Fanconi → DEB test
Question 3
•
And now, which tests are necessary to
conclude the diagnosis?
1.
2.
3.
4.
5.
Karyotype
Investigation for PNH
DEB test
1+3
All the above-mentioned tests
Question 4
•
Karyotype was normal. Expression of CD66b and
CD14 on granulocytes or monocytes could not be
performed due to the small number of cells in the
peripheral blood. DEB test was negative.
•
What is now the most probable final diagnosis?
1.
Aplastic anemia
2.
Myelodysplastic syndrome
3.
Agranulocytosis due to clozapine
4.
Acute leukemia
5.
Fanconi’s anemia
Question 5 - introduction
• After one month, the infection resolved
and the patient was discharged. The
psychiatrist changed clozapine to
risperidone and DZP.
• PB counts: Hb : 8.8 g/dl; leukocytes: 5.7 x
109 /l; neutrophils: 3.1 x 109 /l; platelets:
100 x 109 /l
Bone marrow cytology
BM:
erythroblasts: 24%;
granulocytes: 63%
blasts: 0.5%.
Megakaryocytes:
+++
Question 5
•
What is the cause of the increased granula
found in the granulocytic precursors?
1.
2.
3.
4.
5.
a sign of persisting infection
due to the use of G-CSF
indicative of a myelodysplasia
due to BM recovery
a sign of myelotoxicity (psychotropic drugs)
Question 6
•
Why does the hemoglobin and the platelet did
not fully recover?
1. The patient has aplastic anemia
2. Vitamin deficiency due to the use of parenteral
nutrition
3. Myelotoxicity of the antibiotics used
4. the new psychotropic agents are also
myelotoxic
5. The patient suffers from PNH. This could not
be clarifyed during the infection and low
granulocyte counts.
• Anemia aplástica excluída: não houve
pancitopenia desde o início. Os mielogramas
são celulares
• HPN: não há dado outro dado clínico que
sugere. Mas, se houver dúvida, pode-se repetir
• Deficiênica vitamínica: deveria ter sido dosado
ácido fólico e B12. Pode ocorrer em pacientes
com sepse. Ver a nutrição parenteral e
suplementar. A segunda citologia fala contra
Agranulocitose - causas
• Infecções –
Virais: HIV, dengue, hepatite, CMV
Bacterianas: Gram – tbc, febre tifoide
Fungo: histoplasmose
Protozoários: calazar, malária
• Autoimunidade – d. Still, LED, etc
• Nutricionais - distúrbios alimentares, anemias carenciais
Medicamentos e agranulocitose
• Analgésicos: dipirona, indometacina, etc
• Psicotrópicos: clozapina, risperidona, diazepam,
haloperidol
• Anticonvulsivantes
• Anti-tireoidianos (tiouracil)
• Antibióticos, drogas cardiovasculares (captopril,
propanolol, nifedipina)
• etc
SEV conclusion
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Question 1 - 1
Question 2 - 4
Question 3 - 5
Question 4 - 3
Question 5 - 2
Question 6 - 4