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[JAMA临床挑战]:接受化疗患者外周血中的原始细胞
2024年03月19日 临床话题, 模拟诊室 [JAMA临床挑战]:接受化疗患者外周血中的原始细胞已关闭评论

JAMA Clinical Challenge 

October 6, 2023

Peripheral Blasts in a Patient Receiving Chemotherapy

Sabin Kshattry, Terri L. Parker, Scott F. Huntington

JAMA. 2023;330(16):1581-1582. doi:10.1001/jama.2023.17117

Case

An 80-year-old man with stage II bladder carcinoma (T2NXM0) and atrial fibrillation treated with apixaban presented to the emergency department with 1 week of fatigue and 2 days of dyspnea on exertion. One week prior to presentation, he received a fourth cycle of carboplatin/gemcitabine for bladder carcinoma with 6 mg of pegylated granulocyte colony-stimulating factor (G-CSF). The patient reported no anorexia, fever, melena, hematemesis, hematuria, cough, orthopnea, or peripheral edema.

His vital signs were normal except for a heart rate of 103/min. His white blood cell count was 22 × 103/μL (reference, 4-11 × 103/μL), increased from 4.8 × 103/μL 8 days prior. His manual differential, which was previously normal, showed 18% bands (0%-10%), 2% metamyelocytes, 7% myelocytes, 7% promyelocytes, and 6% blasts. His hemoglobin level was 5.2 g/dL (reference, 13-17 g/dL), decreased from 7.4 g/dL, and platelets were 25 × 103/μL (reference, 150-420 × 103/μL), decreased from 268 × 103/μL 8 days prior. Ferritin was 1423 ng/mL (reference, 300-400 ng/mL). Mean corpuscular volume, prothrombin time, international normalized ratio, partial thromboplastin time, fibrinogen, haptoglobin, vitamin B12, and methylmalonic acid values were normal, and results of a direct antiglobulin test were negative. A computed tomography (CT) scan of his abdomen and pelvis was normal. He received 2 units of packed red blood cells and was admitted to the hospital. Flow cytometry identified a small population of CD34+/CD117+ cells (Figure).

Left, Peripheral blood smear showing normocytic anemia with anisopoikilocytosis and leukocytosis with 6% to 8% blast forms. Right, Flow cytometry of peripheral blood demonstrating a small population of white blood cells that stained positive for CD34 and CD117, which are markers of immature myeloblasts.

Esophagogastroduodenoscopy revealed 2 nonbleeding angioectasias in the stomach that were treated with argon plasma coagulation. Three days after admission, his white blood cell count was 27.7 × 103/μL with 4% peripheral blasts, hemoglobin was 7.3 g/dL, and platelet count had increased to 92 × 103/μL without a platelet transfusion.

What Would You Do Next?

  • Perform a bone marrow biopsy
  • Prescribe all-trans retinoic acid
  • Repeat complete blood cell count with differential in 1 to 2 weeks
  • Start cytoreductive therapy with hydroxyurea

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