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CASE PRESENTATION
Dr. Mario Melgar
Guatemala
THE PATIENT
• MDM
• Age: 11 years old
• Origin: Guatemala city
History of Disease
• Dysphagia 3 weeks, treated with antiinflammatories
• CBC: Hyper leukocytosis
• Transfer to UNOP
• July 8, 2008
– Diagnosis: AML M4
– 245,000 WBC
– CSF negative, Thorax negative
– Fever, oral lesions
• Ceftazidime, Fluconazole
• July 10, 2008
– Hypo tension
– ICU
– Vancomycin
• July 12
– Start on chemotherapy protocol (ADE)
– G-CSF
• July 16
– Acyclovir
• July 21
– Withdraw Vancomycin
– Diarrhea
– Neutropenia
• July 22
– Septic shock
– Meropenem
– Amikacyn
– Amphotericyn B
• July 24
– Vancomycin re started
• July 26
– Improvement in clinical condition
– Out of ICU
• July 29
– Amphoterecyn B withdraw
• July 30
– TNC 310
• August 1
– TNC 1780
– Withdraw atbs – 4 hours later fever
– Cultures
– Cardiomegaly in X-rays
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8/11/2008
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8/1/2008
7/30/2008
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7/24/2008
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7/20/2008
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7/16/2008
7/14/2008
7/12/2008
7/10/2008
7/8/2008
CRP
250
200
150
CRP
100
50
0
80000
70000
60000
50000
40000
30000
20000
10000
0
WBC
TNC
• Look back pericardial effusion
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–
–
–
July 11 small pericardial effusion 8mm
July 16 pericardial effusion 10mm
New echocardiogram
August 4 pericardial effusion 15mm, septated
• August 5
– Pericardial drainage and biopsy
• 100 cc serohematic
• 117 WBC (76% Lymph, 24% PMN)
• Stains and cultures negative
• August 7
– Chest CT
• Basal consolidation in both lungs
• Needle biopsy – not enough material
Pericardial biopsy
• In some miocytes and histiocytes
presence of eosinophylic nuclear
inclusions sugesting CMV infection
PERICARDIAL EFFUSION
•
•
•
•
CMV infection?
Other virus?
Neoplasic infiltration?
Drug toxicity?
CMV pericarditis
• Frasca 1980
– Review of viral serositis and pericarditis
– Of 47, 5 influenza viruses, 1 parainfluenza, 1
coxsackie, 1 RSV, 3 mumps virus,, 1 adenovirus,
5 CMV
• Saatsi 1993
– Case report of CMV pericarditis
– Renal transplant recipient
• Campbell, 1995
– 57 pericardial effussions in adults
– 3 culture proven, 1 serological CMV
– 1 infant with congenital
hearth disease
Boll Ist Sieroter Milan. 1980 May 31;59(2):112-20
Int Urol Nephrol. 1993;25(6):617-9. Links
Am J Med Sci. 1995 Apr;309(4):229-34
Other viruses
• Daibata 1997
– 47 yo man, AML
– Pericarditis due to HHV 6
• Aoyama 2004
– 31 yo woman, AML
– Pericarditis
– EBV reactivation
Leuk Lymphoma. 2004 Feb;45(2):393-5
Leukemia. 1997 Jun;11(6):882-5.
Infiltration
• Wong, 2004
– 47 years,
– Constrictive pericarditis
– Etiology: tumor infiltration
• Da Costa, 1999
– 2 year old AML
– Cardiac tamponade at presentation with hyper
leukocytosis
Medical and Pediatric Oncology 32:120–123 (1999)
Circulation. 2004;109:e146-e149
Drugs
• Galer,2003
– Patient with acute mielomonoblastic leukemia
– Pericarditis due to Cytarabine
• Larrea, 1997
– Case report
– ATRA syndrome
– Cardiac tamponade, treatment with steroids
and pericardiocentesis
Haematologica 1997; 82:463-464
Onkologie. 2003 Aug;26(4):348-50
In our patient
• Probably tumor infiltration
• August 7
– Started chemo
– Fever stopped
– Good clinical evolution
– New CT pending for assessment of lung
consolidations
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