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Old 09-21-2012
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Arrow Gyrus Daily Questions; Internal Medicine #13

A 76-year-old man is admitted to the hospital with complaints of fatigue for 4 months and fever for the past 1 week. His temperature has been as high as 38.3C at home. During this time, he intermittently has had a 5.5- kg weight loss, severe bruising with minimal trauma, and an aching sensation in his bones. He last saw his primary care physician 2 months ago and was diagnosed with anemia of unclear etiology at that time. He has a history of a previous left middle cerebral artery cerebrovascular accident which has left him with decreased functional status. At baseline, he is able to ambulate in his home with the use of a walker and is dependent upon a caregiver for assistance with his activities of daily living. His vital signs are: blood pressure 158/86 mmHg, heart rate 98 beats/ min, respiratory rate 18 breaths/min, SaO2 95%, and temperature 38C. He appears cachectic with temporal muscle wasting. He has petechiae on his hard palate. He has no lymph node enlargement. On cardiovascular examination, there is a II/VI systolic ejection murmur present. His lungs are clear. The liver is enlarged and palpable 6 cm below the right costal margin. In addition, the spleen is also enlarged, with a palpable spleen tip felt about 4 cm below the left costal margin. There are multiple hematomas and petechiae present in the extremities. Laboratory examination reveals the following: hemoglobin 5.1 g/dL, hematocrit 15%, platelets 12,000/μL, and white blood cell (WBC) count 168,000/μL with 45% blast forms, 30% neutrophils, 20% lymphocytes, and 5% monocytes. Re-
view of the peripheral blood smear confirms acute myeloid leukemia (M1 subtype, myeloblastic leukemia without maturation) with complex chromosomal abnormalities on cytogenetics. All of the following confer a poor prognosis for this patient except

A. advanced age
B. complex chromosomal abnormalities on cytogenetics
C. hemoglobin <7 g/dL
D. prolonged interval between symptom onset and diagnosis
E. WBC count >100,000/μL
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ans >.........D........
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Old 09-21-2012
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The answer is C. hemoglobin <7 g/dL


Among the prognostic factors that predict poor outcomes in AML, age at diagnosis is one of the most important because individuals of advanced age tolerate induction chemotherapy poorly. In addition, advanced age is more likely to be associated with multiple chromosomal abnormalities that predict poorer response to chemotherapy, although some chromosomal markers predict a better response to chemotherapy.



Chromosome findings at diagnosis are also very important in predicting outcomes in AML. Responsiveness to chemotherapy and survival are also worse if the leukocyte count >100,000/μL or the antecedent course of symptoms is prolonged. Anemia, leukopenia, or thrombocytopenia
present for >3 months is a poor prognostic indicator. However, there is no absolute degree of anemia or thrombocytopenia that predicts worse outcomes.
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