Hey guys,
I'm doing my core IM rotation right now and we had an interesting case last night that I thought I would share with all the Pathology studs since you guys can appreciate it more.
We had a 65 year old gentleman present to our ER with a chief complaint of shortness of breath and weakness X 1day. His O2 sats were 86% on 100% non-rebreather and his PO2 came back about 60, I think. He was very tachypneic. He has a history of polycythemia vera that had progressed to myelofibrosis. He had just finished 2 rounds of chemo with daunorubicin and was being followed closely by his heme-onc. He also had a history of DVT/PE and was on Coumadin 10mg, but had stopped it a few days before. His INR was 2.16 on admission. His platelet count was 31,000. He had massive, painful splenomegaly.
We got his white count back and we had to wipe our glasses because it came back 427,000 with 65% Blasts. So, obviously this guy had transformed into Acute Leukemia. A helical CT was inconclusive so a V/Q scan was ordered which came back as high probability. We consulted Pulmonology, Hematology and Cardiology(he also had an elevated troponin). The Hematologist recommended immediate leukapheresis. He was intubated and taken to radiology for placement of a dialysis catheter. He was then taken back to the MICU where after being seen by the pulmonologist he went into V tach and then asystole. We attempted ACLS protocol for about 35 minutes to no avail. This happened just as the pathologist was about to set up for the pheresis.
Initially it was assumed in the ER that he had a PE, but after seeing his white count we feel that this was more likely pulmonary leukostasis. It presented nearly identical to PE especially with the mismatch on V/Q. Then again I guess he still could have had a PE. His INR was at the low end of therapeutic but he was pretty immobile and had bandages on his legs for non-healing ulcers. The family didn't want an autopsy so we won't know for sure. I thought it was a pretty interesting case, anyway.
I'm doing my core IM rotation right now and we had an interesting case last night that I thought I would share with all the Pathology studs since you guys can appreciate it more.
We had a 65 year old gentleman present to our ER with a chief complaint of shortness of breath and weakness X 1day. His O2 sats were 86% on 100% non-rebreather and his PO2 came back about 60, I think. He was very tachypneic. He has a history of polycythemia vera that had progressed to myelofibrosis. He had just finished 2 rounds of chemo with daunorubicin and was being followed closely by his heme-onc. He also had a history of DVT/PE and was on Coumadin 10mg, but had stopped it a few days before. His INR was 2.16 on admission. His platelet count was 31,000. He had massive, painful splenomegaly.
We got his white count back and we had to wipe our glasses because it came back 427,000 with 65% Blasts. So, obviously this guy had transformed into Acute Leukemia. A helical CT was inconclusive so a V/Q scan was ordered which came back as high probability. We consulted Pulmonology, Hematology and Cardiology(he also had an elevated troponin). The Hematologist recommended immediate leukapheresis. He was intubated and taken to radiology for placement of a dialysis catheter. He was then taken back to the MICU where after being seen by the pulmonologist he went into V tach and then asystole. We attempted ACLS protocol for about 35 minutes to no avail. This happened just as the pathologist was about to set up for the pheresis.
Initially it was assumed in the ER that he had a PE, but after seeing his white count we feel that this was more likely pulmonary leukostasis. It presented nearly identical to PE especially with the mismatch on V/Q. Then again I guess he still could have had a PE. His INR was at the low end of therapeutic but he was pretty immobile and had bandages on his legs for non-healing ulcers. The family didn't want an autopsy so we won't know for sure. I thought it was a pretty interesting case, anyway.
