Question

M.T. is a 58-year-old white female with a history of chronic myelogenous leukemia (CML). She is receiving maintenance therapy with hydroxyurea, with a history of prior treatment with imatinib mesylate. She was recently visiting her sister for several days who has a new grandchild in the home. During her visit, she appeared to develop a viral infection, with a low grade fever and cough. Presently, she is experiencing malaise and reports both her feet have been feeling cold throughout the last 12 hours accompanied by flank pain. When providing her history, she experiences spontaneous epistaxis.

Allergies: NKDFA

Medications:

Multivitamin daily

Hydroxyurea 1,500 mg daily

Review of Systems

General: Denies recent change in weight. She has a history of recent viral respiratory infection with a current report of malaise. She reports frequent fatigue but attributes it to “my leukemia.”

Skin: Denies rash, lesions, or photophobia. Denies brittle nails. Reports recent petechiae along both forearms

HEENT:

Head: Denies head trauma or headache.

Eyes: Last eye exam 9/1/2011, no corrective lenses, denies recent change in vision.

Ears: Denies vertigo, tinnitus, or discharge.

Nose: Denies rhinorrhea, congestion, masses, or lesions. Currently experiencing spontaneous epistaxis. Denies any recent trauma to nose or excessive dryness of membranes.

Throat: Denies sore throat at present and no difficulty swallowing or toothache. Last dental exam 10/2010.

Chest: No wheezing or hemoptysis. Denies shortness of breath and dyspnea at night or on exertion.

CV: States “my feet are cold.” Denies palpitations, chest pain, or syncope.

GI: Denies vomiting, diarrhea, or hemorrhoids. No history of constipation. Does report the presence of mild GI pain with some nausea.

GU: Denies polyuria or hematuria.

Extremities: Report of chronic pain in joints (3/10) and rare (approximately once a month) sharp pains (8/10) in long bones. Report of sternal tenderness.

Neurological: Denies dizziness, syncopal episodes, memory loss, numbness or tingling, ataxia, or seizures.

Physical Examination

Vital Signs:

Temperature: 99.9˚F

Pulse: 100/min and regular

Respirations: 20/min; pulse oximetry 98% on room air

BP: 108/64 mm Hg; repeated 5 minutes later BP: 102/60 mm Hg

Height: 5’4”

Weight: 100 lbs.

BMI: 17.2

General: Alert and oriented in all spheres. She is awake and alert, no acute distress, dressed appropriately for the season.

HEENT:

Head is normocephalic, nontraumatic.

Eyes: Snellen 20/20 Left, 20/30 Right without corrective lenses. PERRLA bilaterally. Extraocular movements intact bilaterally. Visual fields intact by confrontation bilaterally.

Ears: TMs are normal bilaterally, cone of light at 5:00 o’clock on the Right, 7:00 o’clock on the Left, minimal cerumen noted bilaterally.

Nose: No discharge or inflammation noted bilaterally.

Throat: Posterior pharynx is unremarkable.

Neck: No lymphadenopathy present. Jugular venous distention noted at 4 cm above the clavicle at 45˚ head of bed elevated.

Heart: Point of Maximal Impulse (PMI) is found left of the midclavicular line (MCL) at the 4^th intercostal space (ICS). Rhythm is regular with a slightly increased rate over carotid (+2/+4), radial (+2/+4) and very faint over posterior tibial (+1/+4) with absent dorsalis pedal (+0/+4) pulses. Minimal nonpitting edema isnoted from toes to midcalf (1+) bilaterally.

Lungs: AP:Transverse ratio 1:2; clear to auscultation on the right, mild crackles noted on the left base. Sounds are diminished.

Abdomen: No bulges or pulsations, abdomen obese. Bowels sounds X 4 quadrants. Abdominal vascular sounds are present without bruit. Tenderness noted in the region of the spleen and liver using indirect percussion. Spleen is palpable.

Extremities: Muscle strength is symmetrical and intact bilaterally, upper extremities +5/+5, and lower extremities +5/+5. Gait is normal.

Neurological: Awake, alert, oriented X 3, follows commands. DTRs are 2+/4+ bilaterally.

1.What might be contributing to the spontaneous epistaxis of this patient? How does that fit in with other signs and symptoms exhibited by this patient?

Answer 1

Chronic myelogenous leukemia (CML), also known as chronic myeloid leukemia is a form of leukemia which mainly affects the WBCs. In which the increased and unregulated growth of predominantly myeloid cells in bone marrow occurs and these cells accumulate in the blood.

It is treated with tyrosine-kinase inhibitors. It is commonly presented as nonspecific symptoms of fatigue, weight loss, and anorexia. The patients develop signs and symptoms as the disease progresses. These patients with abnormal blood count are prone to bleeding. Prolonged hemorrhage and thrombosis are very common. Leukocytopenia increases the susceptibility of infection of the sinuses, skin, and genitourinary system. Bone pain and enlarged spleen regularly seen in CML.

In the case, patient is facing the attack of opportunistic infection, upper respiratory infection, splenomegaly and bone pain.

The epistaxis is mostly occurred due to thrombocytopenia, abnormally functioning platelets. Splenomegaly also underlines the situation.