MED4 A case of acute monocytic leukemia in a 60-year-old female presenting with symptoms of severe bleeding and DIC, after treated for UTI and Chf. (Medicine).

MED4 A CASE OF ACUTE MONOCYTIC LEUKEMIA IN A 60-YEAR-OLD FEMALE PRESENTING WITH SYMPTOMS OF SEVERE BLEEDING AND DIC, AFTER TREATED FOR UTI AND CHF. Jorge R. Belgadere, MD, and Lonn Guidry, MD. Internal Medicine Department, Louisiana State University Health Sciences Center, Lafayette, La.

A 60-year-old black female was admitted for complaints of intermittent shortness of breath and dark red blood in stool over the past month. Medical history included diabetes and hypertension. Initial physical exam revealed cardiomegaly, pulmonary rales and wheezes. Lab studies found anemia with hematocrit of 23.9% (37-47%), serum creatinine of 1.3 (0.6-1.2), albumin of 3.8, total protein of 8.3, total bilirubin of 2.5, abnormal urinalysis consistent with UTI ([+] protein, [+] bacteria, [+] nitrite). EKG showed atrial fibrillation with rapid ventricular response. CXR revealed cardiomegaly, pulmonary congestion, small basilar infiltrates and effusions. Treatment included diuretics, digoxin, ACE inhibitors, bronchodilators, IV corticosteroids, anticoagulants, and antibiotics. After transfusion for the severe anemia the patient exhibited clinical signs of worsening volume overload, treated with fluid restriction and adjustment of diuretic doses. Cardiology consult excluded myocardial infarction but echocardiogram showed left ventricular concentric hypertrophy (normal systolic function) with dilation of the left atrium; right ventricle, and right atrium. VQ scan was negative for PE. Treatment response was variable. CBC reports noted abnormalities decreasing platelet counts, atypical lymphocytosis and monocytosis. CMV-Igm titers were negative, (+) heterophile/Monospot. By the 8th hospital day the patient status required assisted ventilation in the ICU. Continuing to deteriorate, she showed signs of DIC with vaginal bleeding. After a gynecology consult, abdominal ultrasound revealed a forgotten IUD placed 25 years ago. This was removed and cultured which showed a Staphylococcus haemolyticus (of doubtful significance). Endome trial biopsy showed normocellular proliferative endometrium with no inflammation or purulence. Blood cultures remained negative. Tracheal cultures showed light growth strep group B. Blood smear revealed increased "vacuolated monocytes," later described as Blast forms indicating possible blast crisis . On 11th hospital day, she was hypotensive, failed to respond to resuscitative measures, and was pronounced dead. Autopsy revealed terminal septicemia with leukocytosis; studies of bone marrow, peripheral smear and other organ sections indicated increased monocytes with atypical forms, blast, and plasma cells. Bone marrow was markedly increased for her age group, with an increased number of myelomonocytoid cells present. Sections of the lymph node showed an infiltrate of immature myeloid appearing cells and megakaryocytes.