meghana jadhav
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A 45-year-old man has complained of increasing abdominal girth, fever
and malaise for the previous 4 months. He has denied having a cough. Physical examination shows a markedly enlarged spleen but no lymphadenopathy. Laboratory evaluation shows a normal chest x-ray, hemoglobin concentration of 15 g/dL, a white blood cell count of 45,000 cells/ml with no blasts seen on the blood smear, and a platelet count of 750,000/ml.
The most likely diagnosis is
A. malignant lymphoma
B. acute leukemia
C. chronic myeloproliferative disorder
D. pulmonary TB
E. myelodysplastic disorder
The laboratory evaluation for the differential diagnosis of this problem
might include all of the following tests EXCEPT
A. measurement of leukocyte alkaline phosphatase levels
B. chromosomal evaluation
C. bone marrow aspiration and biopsy
D. flow cytometric analysis
E. determination of red blood cell mass
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megha
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| mani
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1.c
2.d??
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| Malaysian
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My answer for Q.1 is same as Mani's for Q.2 I feel its E(not sure)
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| meghana jadhav
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ans of first is correct......try the second q again...malysian if u have explanation...pl do explain...so that...i can clear my doubt...
i have confusion between ...a and e.....
why u r saying e????
pl....explain.
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megha
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| MLF
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For questions one, the main thing to remember is that in myeloproliferative disorders, the age onset is middle age, you have splenomegaly and an increase in myeloid cells, either erythroid, granulocytic, or megakaryocytic In chronic myelofibrosis, the bone marrow gets replaced by fibrosis, but the megakaryocytes are spared so you have an increase in platelets. You also see anemia and so i would rule out E as answer becausae in anemia, determining red cell mass also helps. Due to less Hb, it should be decreased. I think the answer should be A because an increase in megakaryocyes would not cause an increase in leukocyte alkaline phosphatase, as that would be related to an increase in leukocytes. Hope its rite!!!!
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| bluedusk
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the most likely myeloproliferative disorder in this scenario i think is cml rather than myelofibrosis. in general, i think if you get a general leukemia picture like this, you would get additional details if they were talking chronic myelofibrosis. given an age group, remember the goljan axiom....
-15 = all
15-40 = aml or cml
40-65 = cml
65- = cll
with the paucity of blasts, you're looking at cml. leuk alk phos helps rule out cml, if it is positive. "red cell mass" is code for polycythemia vera and i believe the least helpful marker.
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| Alina T
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this is a really interesting question...
my 2 most likely Dxs would be CML and polycytemia vera. all the findings is the stem match with both disorders, the first one being more common, indeed.
but it could be PV, right? and choice E is definitory for it, as it is the only dis associated with increase in RBC mass.... So y should we exclude it??
Choice A is also a strong one for CML....
it's not very clear for me what we should expect from flow cytometry.....i have only a vague idea about it...can anyone point out in 2 lines what exactly we're looking for by doing this test?
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| snap
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Flow Cytometry provides qualitative measures of various biochemical and biophysical measures of the cells. Depending on staining we can zero in to specific cell components of interest ex: DNA. Its important here as we can analyse the shape and number of chromosomes in CML cells (Ph chromosome, short chromosome 22 etc). so here I agree with bluedusk that the most irrelevant investigation would be red cell mass.
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| mani
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chrmomasomal evaluation is already given directly in option B.moreover i dont think that flow cytometry is very good at analyzing DNA. so wi would still be going for option D as answer to 2nd question
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| meghana jadhav
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answer given for the second ans is ...E.....but i really dont have the explanation for it.......
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megha
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| Malaysian
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Hi meghana,sorry for the detail.The reason why I said it as E is because the question asked for an investigation which help in the differential diagnosis of myeloproliferative disease.Myeloproliferative disease's D/D is mainly leukaemias.
So A....is valid since in leukaemia LAP is reduced
B.I think they are mainly referring to philadelphia chr. here
C.Very important to tell if there is Acute or chronic leukaemia
D.Important in determining CALLA...CD5 in AML
E.Not valid since this only tells if the pateint has a Polycythaemia vera....which is a myeloproliferative disease.
I think the question was phrased poorly causing the confusion amongst everyone.But it shows that every word is important and changes the meaning of the question entirely.
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| meghana jadhav
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thanx malysian....for nice explanation
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