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CASE REPORT

APLASTIC ANEMIA IN AN
ADOLESCENT BOY
Compiled By:

Nurul Citta Banu Putri 100100167


Vincent

100100246

Supervisor :

dr. Olga Rosiyanti Siregar, M.Ked (Ped), Sp.A

CHILD HEALTH DEPARTMENT


H. ADAM MALIK GENERAL HOSPITAL
FACULTY OF MEDICINE
SUMATERA UTARA UNIVERSITY
MEDAN
2014

APLASTIC ANEMIA

Definition : an uncommon but potentially

serious hematological disorder. It is


characterized by pancytopenia secondary
to a hypocellular bone marrow
Etiology : chemical (benzene, pesticides),
drugs
Epidemiology : The incidence of aplastic
anemia in the West is 2/million and about
2- to 3-fold higher in Asia

Pathophysiology

In most cases, aplastic anemia is an immunemediated disease


Exposure to specific environmental precipitants,
diverse host genetic risk factors, and individual
differences in the characteristics of the immune
response likely account for the diseases
infrequency, variations in its clinical behavior,
and patterns of responsiveness to treatment
Immune-mediated T-cell destruction of
marrow
Hematopoiesis (Immune attack leads to
marrow failure Anhematopoiesis)

Diagnosis

History : anemia, thrombocytopenia and


neutropenia. Anemia results in pallor, easy
fatigability, headache, dyspnea, and
tachycardia
Physical Examination : Thrombocytopenia
manifests with petechiae, ecchymoses,
epistaxis, gum bleeding and menorrhagia
Laboratory Finding: pancytopenia, BMP
shows hypocellular bone marrow

Differential Diagnosis

Hypocellular myelodysplastic syndrome


(MDS)/ acute myeloid leukemia (AML)/ acute
lymphoblastic leukemia (ALL)
Hairy cell leukemia
Lymphomas and myelofibrosis
Mycobacterial infections.

Treatment / Supportive Care


Transfusional support
- Packed red cell transfusions must be given to
maintain a safe hemoglobin.
- Platelets must be given to prevent bleeding
and are indicated if the platelet count is < 10

109/L.
- Tranexamic acid is used in the dose of 2-4
g/day in 3-4 divided doses
Prevention of Infections
Treatment of Infection

Specific Therapy for Severe Aplastic


Anemia

Hematopoietic Stem Cell Transplant


Immunosuppressive Therapy
Technical Aspects of ATG Administration
Androgens
New Immunosuppressive Drugs
Role of Corticosteroids
Role of Colony Stimulating Factors

MEDICAL RECORD

Name
: SA
Age
: 13 years 10 months
Sex
: Boy
Date of Admission: February, 1st 2014

Chief Complaint : Pale


History: It problem has already been occurring to this patient
since 1 week. The patient became increasingly pale.
History bleeding gums found since 1 week, volume a little bit.
History bruises found since the first week, the bumps on both
upper arms.
Narrated red spots found over the last 2 weeks on the chest,
upper arms right and left.
History of spontaneous bleeding such as nosebleeds weas not
found, history defecate black was not found.
History of fever was not found, history of cough was not found,
history of cold was not found.
Urinate in the normal range. Defecate in the normal range.
Narrated live in farming areas found.
Family history of suffering from the same complaint was not be
found.
This patient was admitted Hematology Oncology of Child Haji
Adam Malik Medan General Hospital Center. History of blood
transfusion was found last 2 weeks.

Laboratory Result (Samosir General Hospital) :


February, 28th 2014
Hb / Ht / L / T / Ur / Cr : 9.2 / 26.1 / 8600/4000/5.8 / 0.7.

Feeding History
From birth to 6 months : Breast milk only
From 6 months to 9 months: Breast milk with rice porridge
From 9 months to 1,5 years: Breast milk with soft rice
From 1,5 years until now: Family food

History of Growth and Development


Sitting : 5 months
Crawling : 8 months
Standing : 10 months
Walking : 18 months

Physical Examination
Generalized status
Body weight: 30,5 kg, Body length: 133 cm,
Body weight in 50th percentile according to age: 50 kg
Body length in 50th percentile according to age: 162 cm
Body weight in 50th percentile according to body length: 38 kg
BW/BL: 30,5/38 x 100% = 107%
BW/age: 30,5/50 x 100% = 92,4%
BL/age : 133/162 x 100% = 86,36%

Presens status
Consciousness: GCS 15 (E4 V5 M6)
Blood Pressure: 100/60 mmHg
Heart Rate: 88 x/i
Respiratory Rate: 20 x/I
Body Temperature: 36,5oC.
Anemic (+). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (-)

Physical Examination (Localized status)


Head :
Isochoric pupil 3 mm. Inferior palpebra conjunctiva pale (+/+). Icteric sclera
(-/-). Light reflex (+/+). Face edema (-). Inferior and superior palpebra edema
(-/-). Ear and nose were within normal limit. Mouth : pale mucosa (+),
bleeding gums found with volume a little bit.
Neck :
Lymph node enlargement (-).
Thorax:
Symmetrical fusiformis. Chest retraction (-). HR: 88x/i, regular, murmur (-). RR:
20x/i, reguler, ronchi (-). Breath sound: vesicular. Additional sound (-). Ptekie (+).
Abdomen:
Soepel. Liver and spleen unpalpable. Skin pinch returns quickly. Shifting dullness
(-). Double sound (-).
Extremities:
Pulse 88x/i, regular, adequate pressure and volume, warm, CRT < 3. BP: 100/60
mmHg. Pitting edema (-). Hematomas found on the regio volar forearm left
and right with size 2x2cm. Ptekie found on the leg, upper arm, and
forearm left and right.

Differential Diagnosis:
Aplastic Anemia
Acute Lymfositic Leukemia (ALL)
Working Diagnosis:
Aplastic Anemia

Management :
O2 1-2 L/i
IVFD D5% NaCl 0,45% 10 gtt/i micro
Blood transfusion
PRC : (11 9,2) x 4 x 30 = 216 cc (1 bag @175cc)

Diagnostic Planning

Complete Blood Count


Renal Function Test
Liver Function Test
Serum Electrolytes
Blood Glucose ad random
BMP

Laboratory
Findings:
January, 31st
2014

Laboratory Findings: February, 11st 2014

BMP (Bone Marrow Puncture)


Conclusion : Bone marrow shows hypoplasia
and found many of lymphocyte and atypical
cell.
Impression : Hypoplasia Bone Marrow.
Hb/Leu/Trom : 1,8/ 2100/ 4000

FOLLOW UP
February, 2nd February, 11th 2014
S : pale (+)
O: Cons: alert, Temp: 36,7oC. Anemic (+). Icteric (-).
Edema (+). Cyanosis (-). Body weight: 30,5 kg, Body
length: 133 cm.
Mouth : pale mucosa (+), bleeding gums found with
volume a little bit. Hematomas found on the regio volar
forearm left and right with size 2x2cm. Ptekie found on
the leg, upper arm, and forearm left and right.
A: Aplastic Anemia
Management:
IVFD D5% NaCl 0,45% 10 gtt/i micro
Oral prednisone 4-3-3
Folic acid 1x1 mg

DISCUSSION
Theory

Case

The history and clinical findings of


aplastic anemia relate to anemia,
thrombocytopenia and
neutropenia. Thrombocytopenia
manifests with petechiae,
ecchymoses, epistaxis, gum
bleeding and menorrhagia

In this patient, the same clinical


manifestations based on the
theories occur, such as; pallor
due to severe anemia,
thrombocytopenia, leucopenia,
pallor, fever, and gum bleeding

Physical Examination :
Thrombocytopenia manifests with
petechiae, ecchymoses, epistaxis,
gum bleeding and menorrhagia

Mouth : pale mucosa (+),


bleeding gums found with volume
a little bit. Hematomas found on
the regio volar forearm left and
right with size 2x2cm. Ptekie
found on the leg, upper arm, and
forearm left and right.

DISCUSSION
Theory

Case

Laboratory Finding: pancytopenia, Hb / Ht/ L/ T : 1.9 / 5.6/ 3770 /


BMP shows hypocellular bone
4000. Impression of BMP :
marrow
Hypoplasia Bone Marrow.
The treatment for aplastic anemia
is transfusion support, treatment
and prevention of infection,
hematopoiesis stem cell
transplant, and
immunosuppressive therapy

In this patient, the treatment that


given was Packed Red Cell
transfusion, to increase the
hemoglobin level, folic acid, and
prednisone.

Summary
It has been reported, an adolescent boy with the main
complain of pale and was diagnosed with anemia aplastic. The
diagnose was established based on history taking, clinical
manifestation, laboratory finding, and bone marrow puncture.
The patient got PRC transfusion and still need to be followed up

Thank You