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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Granulocytic Sarcoma | 4A0 Case 4 History
Case 4 History ---- This was the first SLCH admission for this 2 year old male referred for evaluation of leukocytosis. Over the 4 months prior to admission the child had developed an ear infection, a single episode of pneumonia diagnosed clinically, and several episodes of diarrhea and tonsillitis. Seven days prior to admission the patient was noted to be less active and more lethargic than normal. Four days prior to admission the patient was taken to the local pediatrician by the parents because of concern for his lack of energy and irritability. He was felt to have a URI at that time and was placed on oral penicillin and an expectorant. The patient did not improve with this therapy and remained lethargic. Two days prior to admission the parents noted the child appeared very pale. Repeat visit to his pediatrician revealed a hematocrit of 5 and a wbc of 400,000. Several ecchymotic areas were noted over the skin, on the legs and on the left forehead. The child was noted to be tachypneic with a respiratory rate of 48. He was afebrile. He had hepatosplenomegaly. Neurologic exam as recorded by three observers showed 2+ and equal DTR. His cranial nerves were intact. Blood smear showed blast cells consistent with non-lymphoblastic leukemia. On the day of admission the child began receiving packed red blood cell transfusions. An LP revealed clear colorless spinal fluid with a protein of 9 and a glucose of 86. Thirty-six cells were noted without acid, 4 cells with acid with a differential of 60% lymphocytes, 20% PMNs, and 20% monocytes. The patient was given Vincristine and Adriamycin IV. On January 22, the child was noted to be more tachypneic with a respiratory rate of 60. He was even more lethargic. He failed to recognize his parents and did not fix and follow objects with his eyes. He sat up without difficulty and moved all extremities well. His pupils at that time were equal, round and reactive to light. The fundus had markedly distended tortuous veins with retinal and preretinal hemorrhages and swollen discs. His deep tendon reflexes were all brisk and his plantar reflexes was extensor. Exchange transfusions were started at that time. At approximately 5:00 PM the patient was noted to have a dilated right pupil. He showed no spontaneous movements and became unresponsive to painful stimuli over his extremities. The patient had full horizontal eye movements on doll's head maneuver on the left but no lateral movement on the right. The patient was started on high dose Dexamethasone therapy at that time. At approximately 8:00 PM the pupils were noted to be equal at 4 mm, dilated and fixed. His respirations were described as irregular and sporadic. At 3:00 AM on January 23, the patient expired.
