CML Case Write Up


Patient’s Details
Name: Mr G
Age: 26
Race: Indian
Occupation: Doctor

HISTORY
G is a 26 year old Indian from India. He comes to Singapore routinely to participate in the BMS trial for his condition of chronic myeloid leukemia (CML).

Mr G was diagnosed with CML 3 years ago in India.

He presented with Melena of 5 days duration. He did not have any associated epigastric pain, and an oral gastro-duodenal scope did not show any positive findings. The melena subsequently stopped spontaneously.

Mr G also felt fullness at the left hypochondrium area and early satiety, both suggesting spleenomegaly. He was able to feel his own spleen and subsequent ultrasound revealed mild hepatomegaly and massive spleenomegaly.

Mr G also has symptoms of anemia which includes lethargy and tiredness but he did not have any breathlessness.

He had a loss of weight of 5 kg over 2 weeks with only a mild loss of appetite.

Mr G did not have any fever or other symptoms of infections. He did not have any bruises or petechiae, gum bleeding or nose bleeding.



Summary
In summary, Mdm Low a 35 yrs old lady delivered her first child prematurely at week 26+5. She was given corticosteroid and tocolysis delayed labour by 27 hours to allow time for the corticosteroid to be beneficial. Both she and her child are currently in stable condition.

PHYSICAL EXAMINATION
Mdm Low was noted to be alert and well. Her mood appeared to be good. She was not pale and she had no pallor.
Her vital signs are stable with her BP at 130/80mmHg. Pulse rate at 72 beats per minute and RR at 15 cycles per min. She was afebrile.

Examination of her thyroid and cardiorespiratory systems revealed no significant abnormailities. Breast and episotomy wound examination was not performed at the patient’s request. I would have looked for any signs of tenderness in the breast that might indicate mastitis and good healing of the episotomy wound.
Her uterus is well contracted and there are no other significant findings at the abdomen. Her calf muscles were supple.

Investigations
Full Blood Count:
A full blood count to look at the hemoglobin level is helpful as it was low after labour at 8.0g/dl. Her last hemoglobin level was on 01/11/05 (1 day before discharge) and was at 8.3g/dl. This is good as it is on an upward trend and she is currently not having any problems with anemia.
Checking the platelets and white cell count would help to check if there are any infections on going.

DISCUSSION

1) List the chief abnormalities in this case, the diagnosis and diagnostic points.

The chief abnormality in this case is preterm labour.
The Definition of preterm labour is the expulsion of a viable infant before the normal end of gestation1. Therefore a preterm delivery is when preterm labour results in delivery between the 26 to 37 weeks gestation. In clinical setting, labour is suspected when the patient suffers painful and regular contractions which lead to cervical changes. In our patient, it is possible that the bleeding per vagina she was complaining was “show” or a cause of the preterm labour. This was supported by regular painful contractions and dilatation of the cervical os that followed. I would have also checked for effacement and the engagement.
There are 3 common ways to calculate the gestation age. The Gestation age of the neonate is best calculated in a dating ultrasound scan in the 1st trimester which was the case in my patient. A dating scan in the second trimester is less accurate but nevertheless important especially when the menstrual history is unclear. Failing which it can be based from the last menstrual period from the history or by the baby’s development after birth (Dubowitz score).

2) Could any of the abnormalities have been avoided?

To consider if premature labour can be avoided, we need to look at the causes and the risk factor for premature labour.
The causes include the following:
A) Maternal Factors: Cervical incompetence, uterine abnormalities, renal diseases, malignancy, multiple pregnancy.
B) Obstetric Complications: Pre-ecalmpsis, antepartum hemorrhage, infections during pregnancy, premature rupture of membrane.
C) Fetal Factors: Fetal distress, growth retardation, fetal abnormalities.

Risk factors include:
a) pregnancy at age before 16
b) Lower socioeconomic status
c) BMI less than 19.0
d) Cigarette Smoking

However more than 50% of the patients who deliver prematurely do so spontaneously without any of the risk factors2.

Therefore, the 1st approach is to reduce the risk factors. The physician can persuade the pregnant lady to give up smoking. While we understand the possible causes in some of the preterm labour, most of them cannot be prevented. Treatments of the causes often do not change the course of preterm labour. Studies are still inconclusive on the efficacy of reducing the incidence preterm labour that results from these treatments. There have been 2 well studied treatment options which are the use of antibiotics and cervical cerclage. The use of cervical cerclage in high risk women to prevent preterm labour is controversial. Different studies have yielded different results. Treatment of bacterial vaginosis with anitibiotics may reduce the incidence of premature labour3.
Therefore, much more research has to be conducted before we can devise new and effective ways of reducing the rate of premature labour.

3) Was the treatment given the best possible

She was well investigated for the episode of bacterial vaginosis and was given appropriate treatment.
The current treatment for premature labour is mainly based on delaying the delivery through tocolysis. This is to prolong the labour for at least 24 to 48 hours so that the corticosteroid can be beneficial.
. Therefore, my patient has received good treatment and care for her premature labour.
In this episode, my patient was given Salbutamol as tocolysis. While Salbutamol has been proven to be efficacious as tocolytic agent5, the use of nifepedine (Adalac) as a tocolysis has been preferred by some specialists. They stated the reduced side effect profile of nifepedine as the reason. A meta-analysis comparing studies involving beta adrenergic agonist and nifedipine showed reduced interrupted treatment due to side effects in using nifedipine6. However, it should be noted that occurence of pulmonary edema with salbutamol only about 1 in 400.


Antibiotics were given to treat any possible subclinical infections of the genitals and the urinary tract. While the use of antibiotics is controversial in preterm labour(see below), it is appropriate in this patient since she has a history of bacterial vaginosis in the 1st trimester.
There are currently no guidelines on whether preterm babies should be delivered via normal vagina delivery or via a caesarian section, although most specialists would agree that it should follow the normal indications of term babies.

4) What were the reasons for adopting such a line of treatment

She received flagyl for bacterial vaginosis in the 1st trimester. Reviews have suggested that abnormal changes in the normal flora of a pregnant lady are a risk factor for premature labour. Treatment should begin as early as possible before the inflammatory response leading to irreversible tissue damage has occurred so as to effectively reduce the chances of preterm labour6. This is because studies have suggests that it is the inflammatory response rather then the infection itself that might be the cause of premature labour.

Data from the KK hospital shows a 75 percent survival rate in preterm babies at gestational age of 26 weeks and discussions with the neonatlogist suggest that 26 weeks is the common cut of age in which the neonatal team would prefer to resususitate the baby as the survival rate of a 25 week neonate falls to 56 percent.
Also, the fetal weight is estimated through ultrasound as the survival rate of an infant more than 750g would be more than 70 percent.
These predictive values help the team and the parents come to a decision on the resuscitation plan for the neonate and their prognosis.

The use of antibiotics in preterm labour is not a currently recommended treatment. When it is done, it is often because of the suspicion that a sub-clinical infection may be present. Studies until now have conflicting results in the use of antibtiotics in preterm labour. Some have reported a prolongation of gestational age7 while others showing no similar effects8.
The administration of corticosteroid has been shown to promote lung maturity in the neonate and reduces the severity and incidence of respiratory distress syndrome in the neonate. It has also been shown to reduce the incidence of Necrotising enterocolitis. The use of tocolysis in this context is to allow the corticosteroid to have at least 24 hours so that the corticosteroids can work optimally9.

5) Were there other ways of treatment which might have been considered? Why were they not used?

There have been recommendations to use fetal fibronectin as a predictor of premature labour and thus allowing the team to better prepare for preventive and treatment options. However, there have been doubts regarding its widespread use due to its low specificity10. A recent New Zealand study also concluded that although the use fibronectin assays have allowed shorter hospital stays, less use of tocolysis and corticosteroid, the neonatal outcome and the total hospital expenditure remains approximately the same as without the assays11. Therefore, the use of fetal fibronectin is not routinely recommended in most cases.

6) Give a brief comment on the case. What lessons did you learn in the management of this case?

Although the main abnormality in this case is premature labour, there are many issues to grabble with in normal obstetrics practice which includes subfertility and the use of IVF.

This case has also clearly illustrated the importance of early and continuous antenatal care so that any pathology or abnormalities can be picked up early. This would allow early commencement of treatment for best results and also allows time for teams to be assembled and plans to be made.

I have learnt the normal pathway of management for preterm labour and the indications and side effects of tocolysis. The importance of a team approach to such a patient is emphasized in my study of this case.

Although it was not discussed in this write up, counseling and patient education is particularly important in the case of premature labour. Predelivery high risk consults are available in all obstetrics hospital in Singapore to discuss the risk and causes associated with preterm labour to high risk patients. This not only allows the patient to understand the actions of the team and therefore puts their mind at ease, but will also ensure that they do not put the blame of the preterm labour on themselves.

Post delivery counseling is equally essential to help educate the parents of the care for their babies. This also helps them understand the risks of having another preterm baby and thereby helping them in future family planning. It should be conveyed to parents that although preterm labour is associated with subsequent preterm birth, this is an insensitive markers for recurrences12.
There are many complex issues regarding the management of preterm labour that are still being debated by the specialist at this point Despite this, a clear guideline is necessary in the management of preterm labours to ensure a good outcome. This was learnt through the study of this case. The learning issues that were taught, read and learnt during this case also provided a good footing to approaching all other kinds of obstetrics and medical cases with a logical, evidenced based and holistic care for my patients.

Continuation to the case study. :)
So any supporters for South Korean in the FIFA soccer world cup?

Differential Diagnosis
Madam XXX is likely to have painful pheripheral neuropathy on all 4 limps and I would like to propose the following aetiologies
1) Toxic causes
In view of her recent intake of ciprofloxacin although this is not a common agent that causes peripheral neuropathy.
Possible poisoning by toxins like arsenic are such substances are sometimes found in high levels in traditional Chinese medication.
2) Inflammatory Causes
She recently had a gastrointestinal infection which could lead to a sequelae of inflammatory demyelinating disease, although this usually presents with more motors symptoms. An atypical presentation of Acute Inflammatory Demyelinating Polyradiculoneuropathy(AIDP) is possible
3) Autoimmune causes
Autoimmune causes are possible although she has not showed any other signs of an autoimmune disease. This is more important since she had a recent allergic reaction to ciprofloxacin.
Other etiologies to consider:
Diabetic amyotrophy
Although the course is usually more chronic.
Nutritional Causes
Vitman B12 and folate are possible causes although the course is also usually more chronic and chronic deficiency of are not common in Singapore.
AIDS related neuropathy
The history does not suggest this, however it is noted that true sexual history of the patient and her partners are not easy to elicit.

Continuation to the case study. :)
So any supporters for South Korean in the FIFA soccer world cup?

Differential Diagnosis
Madam XXX is likely to have painful pheripheral neuropathy on all 4 limps and I would like to propose the following aetiologies
1) Toxic causes
In view of her recent intake of ciprofloxacin although this is not a common agent that causes peripheral neuropathy.
Possible poisoning by toxins like arsenic are such substances are sometimes found in high levels in traditional Chinese medication.
2) Inflammatory Causes
She recently had a gastrointestinal infection which could lead to a sequelae of inflammatory demyelinating disease, although this usually presents with more motors symptoms. An atypical presentation of Acute Inflammatory Demyelinating Polyradiculoneuropathy(AIDP) is possible
3) Autoimmune causes
Autoimmune causes are possible although she has not showed any other signs of an autoimmune disease. This is more important since she had a recent allergic reaction to ciprofloxacin.
Other etiologies to consider:
Diabetic amyotrophy
Although the course is usually more chronic.
Nutritional Causes
Vitman B12 and folate are possible causes although the course is also usually more chronic and chronic deficiency of are not common in Singapore.
AIDS related neuropathy
The history does not suggest this, however it is noted that true sexual history of the patient and her partners are not easy to elicit.

World Cup

Hmm, wierdly not many people seems to be intersted in medical case reports. I wonder if it's because majority are having their summer break now.
How about talking about world cup statistic, about rates and bets?

Today will be the Physical Examination section

Physical Examination
Madam XXX’s physical examination shows signs of peripheral neuropathy.
I say this because on her palmar and dorsum of her hands and on her lower limbs from knew down bilaterally, she has decreased pin prick sensation and a loss of vibration sensation. Her proprioception was lost in her lower limbs but was intact in her upper limbs. Also she showed dry skin on her hands and feet which might suggest an autonomic involvement.
She feels pain when she touches her own hand and it is worst on the pulp of her fingers.
Her tone was normal on all four limbs. She had brisk biceps, triceps and knee reflexes and absent Supinator and ankle reflex. Plantar reflexes could not be elicited.
Her power was weak at about 4 for her proximal muscles and 3+ for her distal muscles in both her upper and lower limbs. Although it should be noted there seemed to be variable effort on testing and that her power of her lower limbs were inconsistently weak as compared to her ability to walk.
She showed no cerebellar signs and was Romberg positive. She was able to walk although she was somewhat atypically unsteady.
Other neurological and abdominal examination revealed no abnormalities.
There were no dermatological signs suggesting any autoimmune disease.
She did not show any signs suggesting endocrine disorders of the thyroid and diabetes.
Other systems examined were also normal.

Sumamry
In summary, Madam XXX shows signs of glove and stocking painful peripheral neuropathy affecting pain, vibration, proprioception and possibly autonomic functions of her limbs bilaterally. Her power was weak but seemed to be effort related.

Case Reports

As a Medical student,I do many medical case reports every year and I think they are a good way to learn. However, I relise little people actually share their reports although doing so would be a very good way to learn from each other.

I shall start today wittg the History of a Neurological problem. No identities or names are published.

CASE WRITEUP 1 (Neurology)

Presenting complain.
Madam XXXis a 40 year old lady who was admitted to neurology for numbness of her distal upper and lower limps bilaterally, accompanied by allodynia of her palmar surface of her hands. She also complains of weakness of her hands and foot bilaterally.
Her symptoms of numbness, allodynia and weakness started 3 weeks ago, accompanied by rashes which were papular and appeared all over her body. These symptoms started a day after she started on Ciprofloxacin which was given to her for suspected gastroenteritis which started 4 weeks ago. The numbness has since not resolved although it did not worsen.
Her numbness was localized to her dorsal and palmar surface of both her hands and to the bilateral lower limps from knee downward. Her numbness was so severe that she did not realize that she suffered a burn on the dorsum of her left hand. She complains that the numbness of her legs has caused her to feel unable to balance. The numbness remained there throughout the day.

When Madam XXX touches her palmar surface of her hand, she feels what she describes as “chisel” pain, which upon explanation is the kind of pain when someone lies on his own hands for a long time. This pain was brought on by simple activities of shaking hands or using the mobile phone’s keypad to send an instant message. The pain will not be present so long as she does not touch anything. The pain is worst on the pulps of her fingers and is equal in both her hands. The allodynia started with the numbness and has not gotten worst or better since then.
Also, Madam XXX feels that she is weaker in the power of her hand muscles and foot since the numbness started. She claims that she has difficulty when carrying gripping objects with her hands and feels weak and less able to balance when she walks.

Other Significant history

This is Madam XXX 3rd hospitalization in a month.
She was first admitted 4 weeks ago on the 6th of May for diarrhea, vomiting and dehydration. During that episode, she also complained of central epigastric pain which comes on and off for a few months and also black watery stools. She was treated for her dehydration and for gastroenteritis and discharged after 5 days with ciprofloxacin.

1 day after taking ciprofloxacin, she realized that she had rashes all over her body. Also she started to feel numbness of her hands and legs together with allodynia and weakness of her limbs as described above. She came to the hospital immediately as she suspected an allergic reaction and was admitted.
During the admission, she was found to be anemic during a full blood count and further investigations revealed a bleeding gastric ulcer. Her rashes resolved after a few days and she was treated for her gastric ulcer disease. However, she was not started on any antibiotic therapy.
Her numbness, allodynia and weakness remained after she was discharged but she assumed it’ll go away with time. She complained to Gastroenterologist about the symptoms of numbness not resolving during her follow up 1 week ago on the 3rd of may and was then advised to be admitted.

Past History
She was hypertensive for 10 years and has been on regular follow up with her GP.
She has no history of diabetes or thyroid diseases.
She has no other significant medical history of note

Social History
She does not smoke and does not drink.
She lives with her husband who is a lorry driver and her 4 daughters. Her eldest daughter is working while the other 3 are schooling and she has no financial or family problems.
Her husband has been her only sexual partner for her life.
She is not a vegetarian and takes a normal diet.


Occupational History
She works as a ward attendant in Ang Mo Kio Community hospital. She does not handle any organic solvents or toxic substances other than the normal soap and detergent.

Family History
She has no family history of peripheral neuropathy.

Drug History
She is allergic to Ciprofloxacin.
She used to take Jamu( traditional medicine) for women vitality and strength which she bought off a traditional medicinal shop but has stopped 6 years ago. She does not know the constituent of the Jamu.

Summary
In summary, Madam XXX presents with 3 weeks of numbness, allodynia and distal limb weakness. She was treated for an gastroenteritis 3 weeks ago with ciprofloxacin which she was found to be allergic to, and had taken Jamu frequently 6 years ago.