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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Granulocytic Sarcoma | 3A0 Case 3 History
Case 3 History ---- The patient was a 65 year old right handed woman who was in her usual state of good health until August 1st with the development of mild increased fatiguability for two months prior to that time. On August 2nd, she felt chilly and noted a fever of 102°F. She also developed pain in her left heel which did not respond to a local steroid injection. In addition, she noted the onset of painful bleeding gums, weakness and dyspnea on exertion with chest tightness. She returned to her physician on the 8th of August when numerous ecchymoses and hematomas appeared on her extremities. A CBC done in her physician's office indicated a white count of more than 100,000 mostly immature forms. On physical examination, positive physical findings included a blood pressure of 80/60, pulse rate of 140 with orthostatic dizziness. There was widespread bleeding into her skin. Stool guaiac was 4+ positive. Her gums were friable and bled with minimal stimuli. Bilateral submandibular rubbery non-tender lymph nodes approximately 3 x 2 cm. in size were noted. There was no hepatosplenomegaly. Initial laboratory determinations revealed a hemoglobin of 9.6, a WBC of 300,000 and a platelet count of 55,000. Her creatinine was 2.2, protein 21%, fibrinogen 23 mg% and peripheral smear showed multiple blasts with indented nuclei, but no Auer rods. Treatment included Allopurinol, fluid therapy and anti-leukemia therapy with hydroxyurea, Vincristine and Prednisone. Nonetheless, on the day of her admission, she became suddenly disoriented in all 3 spheres. Continued bleeding from puncture sites was noted. There were no seizures, neck stiffness or focal signs noted at that time. By 8:45 p.m. bilateral Babinski signs appeared; with absent corneal reflexes and papilledema. At that time a neurology consult was obtained and exam by the neurology resident on call at 10 PM indicated that the patient was unresponsive to deep pain, her left pupil was irregular at 3 x 2 mm. and fixed. The right pupil was iatrogenically dilated. There was no response to OCM's and cold water calorics. Gaze was dysconjugate. The right fundus revealed 2 retinal hemorrhages. Flaccid quadriparesis with only a left biceps reflex developed. Bilateral Babinski's and possible central neurogenic hyperventilation were described. At 11:45 PM the patient was noted to be bleeding profusely in her pharynx and her trachea with respiratory obstruction despite almost constant suctioning. There was a respiratory arrest at 11:35 PM followed by "agonal breathing." No attempt was made at resuscitation and the patient was pronounced dead at 11:45 PM.
