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gingival bleeding

bleeding tissue of upper and lower jaws that surround the base of the teeth known as gum (gum bleeding)

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20 yo male

gingival bleeding -one day duration

easy fatigability , headaches and few episodes of nose bleed

no significant past medical or surgical history

no smokes nor drinks alcohol

not taking any regular medication

No history of allergy to drugs reported

Family and social history were unremarkable

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20 yo male

stable immune system compare to infants and elderly

less prone to infection

chances of getting x linked inherited diseases

gingival bleeding -one day duration

it could be because of inflammation - acute

lack of vitamin C

defects of coagulation fibrinolytic system

absence of fibrin mesh due to secondary hemostasis

any bleeding should stop in a few minutes

easy fatigability , headaches and few episodes of nose bleed

anaemia (fatigue and headache)

lack of iron (fatigue) = less o2 transportation

nose bleed= early sign of leukemia , or physical injury

headache= lack of blood in our brain due to anaemia

lack of iron can cause blood vessel to rupture easily and cause bleeding

no significant past medical or surgical history

no inherited diseases

might not have any chronic diseases before

not immunocompromised

no smokes nor drinks alcohol

less exposure to chemical reagents eg: carcinogen

no DNA mutation

alcohol can cause folate deficiency, since not taking alcohol, anaemia is not due to alcohol

not taking any regular medication

not immunocompromised

not taking anticoagulant

No history of allergy to drugs reported

all symptoms are not because of allergic reaction

Family and social history were unremarkable

no x linked inherited diseases

social history- have healthy lifestyle

safe work place

differential diagnosis

anaemia

inflammation

iron deficiency anaemia (IDA)

clotting disorder

acute myeloid leukemia

further question / examination

vital sign

physical examination

FBC and FBP

coagulation profile

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ecchymotic skin lesion

-bruises

-bleeding occur out of BV

cytochemistry study

-deal with detection of cell constituent by biochemical analysis and visualization technique

typical Faggot cells

-promyelocyte found in APL

-presence numerous Auer rods

D-Dimer

-by product in blood protein and breakdown process

disseminated intravascular coagulation (DIC).

-condition that cause abnormal blood clotting through out the body's blood

International normalized ratio (INR)

-standardized measure to monitor and access the effectiveness of oral anti-coagulant therapy

Blood urea serum electrolytes (BUSE)

-test that provide info on renal function especially in excretion and homeostasis

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pale with multiple ecchymotic skin lesion

lungs were clear and no organomegaly found on abdominal examination

no evidence of regional lymphadenopathy

abnormal mononuclear showing Auer rods in the cytoplasm with few typical Faggot cells

consistent with the diagnosis of acute myeloid leukaemia (AML)

abnormal blood coagulation tests accompanied by progressive

thrombocytopenia, decreasing fibrinogen, and elevated D-Dimer

levels

evidence of disseminated intravascular coagulation (DIC)

VITAL SIGN:

pulse rate (HIGH)

LABORATORY RESULT:

Hb, Hct, neutrophil, lymphocyte, platelet count, plasma fibrinogen (LOW)

abnormal mononuclear cell , C-reactive protein (HIGH)

Prothrombin time , APTT (PROLONGED)

INR, D-dimer assay (HIGH)

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pale

-low production Hb and RBC level

multiple ecchymotic skin lesion

-due to BV ruptured under skin

-primary haemostatic defect ( due to vascular wall and platelet interact to limit blood loss from damage BV)

lungs were clear (palpate) and no organomegaly found on abdominal examination

-no cavitation in lung, no infection

-lung without swelling, blockage and mucous accumulation

-spleen and liver normal (no haemolytic anaemia)

no evidence of regional lymphadenopathy

-(no haemolytic anaemia)

-no cell damage in lymphoid stem cell

abnormal mononuclear showing Auer rods in the cytoplasm with few typical Faggot cells

-presence on faggot cell indicate APL

consistent with the diagnosis of acute myeloid leukaemia (AML)

- presence of Auer rods

abnormal blood coagulation tests accompanied by progressive thrombocytopenia, decreasing fibrinogen, and elevated D-Dimer

levels

- decrease of platelet progressively (lead to bleeding)(indicate cancer specifically leukemia

-activation of coagulation system cause elevated d-dimer level

-elevated d-dimer indicate infection, cancer, pregnancy, venous thromboembolism

-decrease fibrinogen cause defect in secondary haemostasis (in 2nd, stable fibrin clot formation followed by coagulation processes and fibrinogen is converted into fibrin by thrombin due to this clot occur)

-coagulation factor decrease and not activated

evidence of disseminated intravascular coagulation (DIC)

-example of low level platelet and activated coagulation system coexist form micro clot in BV clotting and bleed occur simultaneously

-associate with APL (myelocyte trigger activation of coagulation cascade lead to DIC)

VITAL SIGN:

pulse rate (HIGH)

-deficiency of RBC

LABORATORY RESULT:

Hb, Hct, neutrophil, lymphocyte, platelet count, plasma fibrinogen (LOW)

-Hb, Hct indicate anemia

-platelet (due to overstimulation coagulation process)

-plasma fibrinogen ( due to 2nd hemostasis defect)

abnormal mononuclear cell , C-reactive protein (HIGH)

-leukemia cause abnormal proliferation mononuclear cell

-CRP related to(inflammation due to skin lesion) (marker for AML pt with neutropenia)(irritation of BM)

Prothrombin time , APTT (PROLONGED)

-indicate low level clotting factor

-defect in common clotting pathway

INR, D-dimer assay (HIGH)

-D-dimer due to activation coagulation system

-INR due to low level platelet, takes longer time to blood clot occur

differential diagnosis

anaemia (associated symptom)

inflammation ('')

iron deficiency anaemia (IDA) boek caju

clotting disorder ('')

acute myeloid leukemia (specifically APL) (Auer rods presence)

further question / examination

vital sign

physical examination

FBC and FBP

coagulation profile mantapzz

cytogenetic karyotyping (presence translocation of chromosome 15 and 17 for leukemia)

immunophenotyping

MANAGEMENT:

Vit A administer (induce differentiation WBC)

chemotherapy

transplantation

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typical chromosomal translocation- a distinct interchange between chromosome

Fluorescence in situ hybridization- test to look at gene or cms in cell and tissue

all trans-retinoic acid (ATRA)- biologically active form of vitamin A

idarubicin- given IV with other medicine to treat AML

complete remission- loss of all signs of cancer due to treatment

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chromosomal translocation t(11;17)

results of fluorescence in situ hybridization (FISH) for the fusion gene was consistent with the diagnosis of acute promyelocytic leukemia (APL)

prompt treatment of the DIC-related bleeding

reatment with specific combination

chemotherapy (all trans-retinoic acid (ATRA), idarubicin, and

arsenic trioxide)

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chromosomal translocation t(11;17)(non-accute)

-Rare condition, t(15:17) is common for APL

results of fluorescence in situ hybridization (FISH) for the fusion gene was consistent with the diagnosis of acute promyelocytic leukemia (APL)

-FISH result indicate that genetic abnormalities

prompt treatment of the DIC-related bleeding

-Supportive treatment such as plasma transfusion to replace blood clotting factors

treatment with specific combination

chemotherapy (all trans-retinoic acid (ATRA), idarubicin, and

arsenic trioxide)

-Treatment for APL

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APL associated with DIC

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