Dr. Wael Lotfy Heikal M.B.B.

CH, MSC Clinical Pathology Pathologist Khasab Hospital Laboratory

A football player who had dropped from the team

A 35 year-old man was dropped from the

football team.  He admitted to the coach that he had been feeling unusually tired for the last 6 months and had occasional episodes of sweating, especially at night. He went to his family doctor.

The only additional symptom that he mentioned

was occasional discomfort in his left upper abdomen.

He didn't smoke and he consumed 20 units of

alcohol weekly . He had never been in hospital , was taking no medication and denied the use of recreational drugs.

What might be causing his symptom?

y Fatigue could be caused by anaemia

or depression , and " sweating" could be a manifestation of infection.

How is sweating evaluated?

y Ask: 'Did you have to change your bed clothes because of the night sweat? y Anxiety, hyperthyroidism, infections( e.g. tuberculosis) and some hematological malignancies( e.g. non-hodgkin's lymphoma, chronic myeloid leukemia) can cause sweating. y A travel history should be taken since infections ( such as malaria), can present in this way.. y A full physical examination should be undertaken.

What should be done next?

y A full physical examination. y The man appeared healthy. y There was no evidence of weight loss and the only

abnormal finding was an enlarged spleen, palpable 4cm below the left costal margine on quiet inspiration.
y There was no lymphadenopathy & his chest was

clinically clear.

Where is the spleen in a healthy individual?

y The spleen lies between the 9th and 11th ribs posteriorly. y It is not normally palpable. y Occasionally in a very thin individual you may be able to palpate the tip of the spleen on deep inspiration. y In this case the spleen was easily palpable on quiet inspiration and, therefore, is significantly enlarged.

What diseases might cause an enlarged spleen in an otherwise healthy looking young man?
 A palpable spleen in an otherwise healthy looking young man suggests either a hematological disorder or an increase in blood flow through the spleen, causing it to enlarge( e.g. portal hypertension).

 In tropical areas infections such as malaria & schistosomiasis may cause a large spleen.

y It is reliable for an

experienced examiner. y However, in obese individuals it may be very difficult to feel a slightly enlarged spleen.

What investigations will define the size of the spleen? Ultrasound examination of the abdomen is a reliable, non-invasive, inexpensive test.

What investigations might help to find the cause of the enlarged spleen?
y A full blood count, blood film, reticulocyte count

and a biochemical screen.

Full blood & reticulocyte count

Patient's results Hb WBC Platelets 14.0 g/dl 55.0x 109 /l 600x109 /l Normal range (male) 13.5-18.0 g/dl 4.0-11.0x109 /l (103 /l) 140-450x 109 /l (103 /l)

Reticulocyte count

6.4%

20-100x109 /l (0.2-1.5%)

The blood film

y There was a marked

increase in the white cell count. y White cell precursors including metamyelocytes, myelocytes, and promyelocytes were present

CML
basophil

blast

neutrophils and precursors

promyelocyte

What do these blood results indicate?

y The Hb is normal and the white cell count is elevated. y White cell precursors are present.,These cells are normally found in the bone marrow and not in the peripheral blood. y The platelet count is also elevated. y This suggests that the bone marrow is overactive and releasing white cells and platelets prematurely into the circulation. y The results of these tests therefore suggest a sever disturbance of the bone marrow, not an infectious disease.

What should be done next?

y He should be referred to a hematologist because he

has significant haematological disorders.

y The patient received an appointment to see a

haematologist 2 days later.

y He was adviced not to play football and to avoid

strenuous exercise.

Why was this advice given?

y It is possible to rupture an enlarged spleen

following trauma.,This could lead to life threatening intra-abdominal bleeding.

y He was interviewed and examined by the

hematologist,who repeated the blood count and blood film and received the results of the biochemical screen & ultrasound examination.

How would the hematologist interpret the blood finding?

y The most likely diagnosis in a young man with a large spleen

and with this blood picture is chronic myeloid leukaemia(CML).

y It is possible in sever infections or when there are marrow

metastases to have an elevated white cell count and to see white cell and red cell precursors in the blood ( a leucoerythroblastic blood picture) .

y There are a number of possible causes of large spleen, such as

chronic infection with malaria, liver disease with portal hypertension, non-Hodgkin's lymphomas and chronic lymphocytic leukaemia, but none of these conditions will have the peripheral finding as described in this patient.

Lactic dehydrogenase and urate ( uric acid) results:

Patient's result Lactic dehydrogenase(LDH) 850 IU/l Normal range 230-450IU/l

Urate(uric acid)

600mol/l

150-470 mol/l (3-8mg/dl)

How are the biochemical results explained?

y The elevated LDH reflects cell death and is non-

specific. y It could be elevated following myocardial infarction, liver damage or premature death of blood cells.,In this case it reflects death of white blood cells. y Similarly the elevated uric acid level in the plasma reflects increased cell turnover.

What should be done next?

y A bone marrow examination was arranged since a

serious hematological disorder was suspected.

From which site was the bone marrow aspirated?

yThe posterior iliac crest. It is the least painful site for the patient and almost completely without hazard. yCare should be taken to make sure that adequate local analegesia is given and there is no bleeding after the procedure.

What investigations would the hematologist request on the sample of bone marrow?

y Slides for microscopic examinations. y A sample should be also sent to the genetics

department for a karyotypic (cytogenetic) analysis

How does the bone marrow aspirate help to confirm the suspected diagnosis?
The slides revealed: 1- a very cellular specimen with increased numbers of white blood cell E/G ratio: 1:4 1: 10 and, 2- increased number of platelet precursors( megakaryocytes), 3-variable fibrosis, increase in reticulin., suggesting increased marrow activity or reduced cell death ( apoptosis).

How should the patient be managed?

y The probable diagnosis should be explained to the patient. y If he has a partner she should be invited, with the patient s permission, to come back in a few days to discuss the result of the result of the outstanding tests. y The patient should be assured that there is no immediate danger, but he advised to remain off work and refrain from contact sports until the diagnosis is clarified.

What medications would the hematologist prescribe?

y Allopurinol, a competitive inhibitor of xanthine oxidase., This drug

will reduce urate(uric acid) in plasma and decrease the risk of gout and renal damage.
y The patient and his partner were given the results 3 days later.

y The cytogenetic analysis revealed a normal number

of

chromosomes but a small chromosome number 22. y This was due to translocation of a portion of chromosome 9 to chromosome 22 and a reciprocal ( reverse) transfer of a portion of chromosome from chromosome 22 to chromosome 9.

Philadelphia chromosome. A piece of chromosome 9 and a piece of chromosome 22 break off and trade places. The bcr-abl gene is formed on

chromosome 22 where the piece of chromosome 9 attaches. The changed chromosome 22 is called the Philadelphia chromosome

Figure, The abnormally small chromosome22, the Philadelphia chromosome

y Molecular consequence of the t(9;22) is the fusion protein BCR ABL, which has increased in tyrosine kinase activity y BCR-ABL protein transform hematopoietic cells so that their growth and survival become independent of cytokines y It protects hematopoietic cells from programmed cell death (apoptosis)

Figure, FISH analysis( fluorescent in situ hybridization) of bone marrow cells showing fusion of BCR/ABL.(F).

Why is this small chromosome 22 called the Philadelphia chromosome and what is its significance?
y The small, abnormal chromosome 22 was first described by two scientists in patients with CML in Philadelphia. y This translocation was the first non-random, reproducible chromosome abnormality to be described in a human cancer. y It is always present in the bone marrow cells of patients with CML., y It is very significant in our understanding of the pathogenesis of CML.

y When portions of different chromosomes come together the

production of an abnormal gene product(protein) occurs.

y In the case of CML the abnormal gene product influences cell

division and programmed cell death (apoptosis).

y The fusion gene on chromosome 22 is called BCR/ABL.

Key point:
y The abnormal chromosome found in CML

causes the malignant phenotype i.e. makes the cells behave in a cancerous way.
y In very recent times this knowledge has

stimulated the development of drugs which specifically inhibit these abnormalities and induce apoptosis of the leukemia cells.

What is the long term outlook for the patient?

y The only definitive treatment is a stem cell transplant from a HLA

compatible sibling.
y As this patient has no siblings he will be treated medically. y A search for a HLA compatible volunteer donor should be carried out

( there are over 6 million donors on the international panel).

y If as suitable donor is found, consideration should be given to a stem

cell transplant, depending to his response to medical treatment.

Can you construct an algorithm for investigations of a patient with a high white cell count and a large spleen?
A patient who has minor symptoms is found to have an elevated white blood cell count

Complete physical examination

Enlarged spleen white cell precursors in blood film

Confirmation of enlarged spleen Marrow for morphological examination and cytogenetic analysis

Normal chromosome number but small chromosome 22. Philadelphia' chromosome Diagnosis: chronic myeloid leukaemia

Medical treatment initially and consideration for stem cell transplantation

Outcome:

y Imatinib mesylate, a new agent capable of

inducing apoptosis in the leukaemia cells, was prescribed.

y He returned to work a few days and was able

to resume a normal life.

y He is seen in the hematology clinic at

monthly intervals.

Thank you