Sabin\u00a0Kshattry,\u00a0Terri L.\u00a0Parker,\u00a0Scott F.\u00a0Huntington<\/h3>\n\n\n\nJAMA.\u00a0<\/em>2023;330(16):1581-1582. doi:10.1001\/jama.2023.17117<\/h3>\n\n\n\nCase<\/a><\/p>\n\n\n\nAn 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.<\/a><\/p>\n\n\n\nHis vital signs were normal except for a heart rate of 103\/min. His white blood cell count was 22\u2009\u00d7\u2009103<\/sup>\/\u03bcL (reference, 4-11\u2009\u00d7\u2009103<\/sup>\/\u03bcL), increased from 4.8\u2009\u00d7\u2009103<\/sup>\/\u03bcL 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\u2009\u00d7\u2009103<\/sup>\/\u03bcL (reference, 150-420\u2009\u00d7\u2009103<\/sup>\/\u03bcL), decreased from 268\u2009\u00d7\u2009103<\/sup>\/\u03bcL 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<\/sub>, 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<\/a>).<\/p>\n\n\n\n![\"\"\/](\"https:\/\/cdn.jamanetwork.com\/ama\/content_public\/journal\/jama\/939252\/jcg230013f1_1697473293.40749.png?Expires=1709960483&Signature=AOQUfR7UnGpNsoaQf70Lq2j4rQFWYBIdO4PwxnNWA6it7giaXUrkC9hOtFl~aAIusjQL54~FGJ2GJekSwhRx~sSmOLC5J3C4Wk4JZ8GhHzGangoxsr14QSFcGz7w-VdxA2k8hCo-qt9YO57QQ6ZDyA8mijCSqzsv3KKwlEXyhPVmm~pn8abdMXkdvuOLrvkJwe-erNQvpHbm74F6SX26ViiTLAea0XL~-Aud-i6VGvcFllcjw4co-mPHHWosL-SQ04vIVMoqvHwIRhIgmA-1n~~QroTnLPGZB6SEeHPlA4MgsUsmW~4CvSZ2M98cfF3QiSmDQoObvBXIhvXTgSTGEg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA\")
<\/figure>\n\n\n\nLeft, 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.<\/p>\n\n\n\n
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\u2009\u00d7\u2009103<\/sup>\/\u03bcL with 4% peripheral blasts, hemoglobin was 7.3 g\/dL, and platelet count had increased to 92\u2009\u00d7\u2009103<\/sup>\/\u03bcL without a platelet transfusion.<\/a><\/a><\/p>\n\n\n\nWhat Would You Do Next?<\/h4>\n\n\n\n\n- Perform a bone marrow biopsy<\/li>\n\n\n\n
- Prescribe all-trans<\/em>\u00a0retinoic acid<\/li>\n\n\n\n
- Repeat complete blood cell count with differential in 1 to 2 weeks<\/li>\n\n\n\n
- Start cytoreductive therapy with hydroxyurea<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"
JAMA Clinical Challenge October 6, 2023 Periphera […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[13,18],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25462"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=25462"}],"version-history":[{"count":3,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25462\/revisions"}],"predecessor-version":[{"id":25469,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25462\/revisions\/25469"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=25462"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=25462"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=25462"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
Case<\/a><\/p>\n\n\n\n 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.<\/a><\/p>\n\n\n\n His vital signs were normal except for a heart rate of 103\/min. His white blood cell count was 22\u2009\u00d7\u2009103<\/sup>\/\u03bcL (reference, 4-11\u2009\u00d7\u2009103<\/sup>\/\u03bcL), increased from 4.8\u2009\u00d7\u2009103<\/sup>\/\u03bcL 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\u2009\u00d7\u2009103<\/sup>\/\u03bcL (reference, 150-420\u2009\u00d7\u2009103<\/sup>\/\u03bcL), decreased from 268\u2009\u00d7\u2009103<\/sup>\/\u03bcL 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<\/sub>, 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<\/a>).<\/p>\n\n\n\n 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.<\/p>\n\n\n\n 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\u2009\u00d7\u2009103<\/sup>\/\u03bcL with 4% peripheral blasts, hemoglobin was 7.3 g\/dL, and platelet count had increased to 92\u2009\u00d7\u2009103<\/sup>\/\u03bcL without a platelet transfusion.<\/a><\/a><\/p>\n\n\n\n JAMA Clinical Challenge October 6, 2023 Periphera […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[13,18],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25462"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=25462"}],"version-history":[{"count":3,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25462\/revisions"}],"predecessor-version":[{"id":25469,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25462\/revisions\/25469"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=25462"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=25462"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=25462"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}<\/figure>\n\n\n\nWhat Would You Do Next?<\/h4>\n\n\n\n
\n