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LECTURE NOTES OF
INTERNAL MEDICINE

Haematology

Dr. Osama Mahmoud Mohamed
Assistant Professor of Internal Medicine

Ain Shams University

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~~I Ji ~I tJ-i-M

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44

II. Manifestations of tissue and organ infiltration:
- Bone: painful tender sternum, pathological fractures.
- Liver ++, spleen ++, lymphadenopathy.
- Skin ~ itching (leukaemia cutis).
- Nervous system ~ infiltration of meninges with headache and

cranial nerve paralysis.
- Retina ~ diminished vision.
- Porta hepatis ~ obstructive jaundice.
- Serous membranes ~ effusions.
- Lung ~ haemoptysis.
- Heart ~ cardiomyopathy.
- Kidney tubular disorder with hyponatremia, hypokalemia.
- Leukostasis with occlusion of the microcirculation e.g

in brain, lung, penis (priapism)
Liver, spleen & L.N++ common with lymphoblastic leukaemia,
hepatosplenomegally occurs in about 30% of AML. Lymphoblastic
leukaemia have better ro nosis than m eloid bad ro nosis .
Investigations:

1- TLC is variable: approximately, 25% of patients having WBCs
counts> 50,OOO/mm3, 50% having WBCs counts between
5000-50.000 and 25% having low count « 5000/mm3) . In most
cases excessive blasts are present in the peripheral blood. In
some patients blasts may be low or absent, see below.

2- RBCs: normochromic normocytic anaemia.
3- Platelets: Thromobocytopenia. 4- Very high ESR.
5- B.M examination (confirmatory): > 20-30% blast cells in B.M.

BM examination will provide material for cytology,
cytochemistery and immunological phenotyping (see later).

6- Other investigations e.g serum uric acid, LDH, renal and
hepatic profiles, CT brain, pelvi abdominal sonar.

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45

D.D. - Fever with sore throat e.g. infectious mononucleosis.
- Other causes of anaemia.
- Other causes of thromobocytopenia.
- Causes of leukemoid picture.
- Causes of I m hadeno ath .

Poor prognosis of acute lymphoblastic leukaemia.
• Age < 2 years or > 10 years • TLC > 100.000
• Platelets < 25.000 • L3 (see later)

Treatment:
General supportive measures

• Anaemia: blood transfusion (the haemoglobin level should be
maintained above 8-10 gm/dl).

• Bleeding: platelet transfusion (the platelet count should be above
10,000-20,000/mm3).

• Infections: neutropenic patients (PNL < 500/mm3) are susceptible
to most of organisms especially gm -ve bacteria and fungi, so
isolation is important plus antibiotics, gamma globulin or
granulocyte transfusion, antifungal, sutrim for pneumocystis carnli,
acyclovir for herpes simplex, gancyclovir for CMV.

• Hyperuricemia: Allopurinol, alkaline urine, hydration.
• Phosphate binders e.g calcium carbonate or acetate for

hyperphosphatemia.
• Leukostasis: is treated by leukopharesis.

• StirnulatiOn·.··pfrnarro~J~?overxusing( .grOWtP<f(ietors:.(~·gm~~IOidp()lor)y
stjm!.J1atingfa?tor~ result in more ~~Ridrecoveryof(PNLq9uQtiqAML

• Oytot() tlerapy ofbulkydisease.maYicaqf)e i uricaqi(j, .•..JJS,IP (tumoUr
Isis($

Treatment of acute I phoblastic leukaemia ALL
I .....Remissioninductionfor 4 weeks .

In this phase the bulk of the tumour is destroyed by combination
chemotherapy (marrow ablation) Le ablation of leukemic cell line in
8M with some sparing of normal marrow (ALL blasts are more
selectively sensitive to chemotherapy than AML blasts). the drugs are:

~
Vincristine

(oncovin)
1.4 mg/m2 up to

2 mg/m2

(day 1,8,15,22)
I.V

+
Adriamycin

40mg/m2 I.V on running
vein (Le with fluids) to
avoid thrombophlebitis

(day 1,8,15,22).
Adriamycin is one of

anthracyclines).

+
Prednisolone
40 mg/m2 oral

daily (day 1-28)

~
L-asparaginase

5000lU IV
(day 15-28)

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