Acute myloid leukemai with guidelines.pdf

Good science ugh d ah

1. Case presentation
ACUTE MYLOID LEUKEMIA
GROUP: D4

2. History
80 years -old male patient , farmer , from Sa’da , married for
50 years with 11 children (youngest 19 years)
Qat chewer and shamma user for ~50 years
Chief Complaint
Severe generalized fatigue and jaundice for 1 week prior to
admission.

3. The pt. known case of DM for 3 years on regular follow up and treatment
HBA1C=5.5
Patient was well until one week PTA when he developed progressive
jaundice associated with severe generalized fatigue leading to inability
to move he has admitted to local hospital and received 4 units of blood
with 2 units of platelets with partial improvement
Patient also complain of itching, exertional dyspnea, dizziness,
palpitations, mild fever, abdominal distension, and dark urine
No change in stool color no bleeding from body orifices , no history of
recurrent chest infection and no skin pigmentation
History of present illness

4. -GIT: anorexia , abdominal discomfort
-CNS : only headache
-GUS: dysuria , oliguria and dark urine
-Endocrine : polydipsia and polyphagia
--Cardiorespiratory :irrelevant
-MSK: irrelevant
-CTD : irrelevant
Review of other systems

5. -Past history: Similar episode occurred 4 months ago
there is history of blood transfusion one time 4 months ago 2
units of blood
Diabetes mellitus for 3 years, controlled (HbA1c: 5.5) with evidence of
diabetic nephropathy on ultrasound
No history of allergy
-Drug history : metformin 850 mg tab , glibenclamide 5 mg tab ,
multivitamin .
-Socioeconomic history: good income
No history of toxin exposure no animal contact

6. GE : patient looks ill , conscious , oriented to TPP , cooperative ,
average body built , lying in semi-sitting position comfortable , pale
with no cyanosis or jaundice nor respiratory distress signs
Bilateral lower limb edema (up to mid-thigh , more on left )
Generalized lymphadenopathy : bilateral cervical , axillary , and
inguinal lymph nodes enlargement (largest ~5 cm, multiple, matted,
mobile, not-tender.
Examination

7. Chest : GAE and bilateral basal crepitation
CVS : S1 + S2 + 0
Abdominal examination:
Inspection: moderate Abd. Distention and epigastric scar ( cautery )
Palpation : soft abdomen ,hepatosplenomegaly (liver span 17 cm, 3
cm below RCM; spleen 6 cm below LCM).
Percussion : tympanic abdomen
Lower limb : pitting bilateral lower limb edema
Following exam

8. Plan of
management
Include :
Investigations and treatment

9. Duty advice :
Daily CBC , blood film for malaria
Manual CBC
Prepare pt for BMA
Septic workup
Blood C/S , Sputum C/S
Send for LFT
Echocardiogram
Insert folly's catheter
Paracetamol 1g SOS
Ceftriaxone 1g iv BD
Septrin 960 mg tab BD
Assist 300 mg iv BD
Zyloric 100 mg tab BD after uric
acid result
Allvent 10 ml syrup TDS

10. Post duty advice
viral marker by Eliza
manual CBC , uric acid , S, phosphate ,
Urine analysis
TB work up ( sputum AFB , MTB )
flow cytometry
Prepare pt for BMA
Doppler us for left lower limb
Ask about Echo
Increase septrin 960 mg tab to TDS
Cefepime 1g iv TDS
Stop Ceftriaxone
Hold allvent
Pantoprazole 40 mg iv OD
RBS chart QID
Input and output chart daily
Chest physiotherapy
Change position every 2 h
Methylcarbylamine 500 mg tab OD

11. Investigations :

12. CBC show :
Leucocytosis
Monocytosis
Basophilia
Anemia
Thrombocytopenia
High esr
Results

13. Manual CBC show:
Leucocytosis with blast
crisis
Thrombocytopenia
Negative malaria smear

14. Chest x ray show :
Bilateral basal
lung white
opacities

15. Finding of urinary
tract infection
Urine analysis :

16. High CK MB
High LDH
Normal serum
electrolyte and
liver function
tests
Biochemistry show :

17. Kidney function test still
within normal
KFT

18. Hepatomegaly 17 cm
Splenomegaly 19 cm
Diabetic nephropathy
Chronic cystitis
Ultrasound show :

19. Histopathology :
Reactive follicular
hyperplasia
No malignancyin this
biopsy

20. Flowcytometry :
Acute myeloid leukemia with
monocytic differentiation

21. Summary of investigations

22. Follow up :

23. 1
st
day post admission :
Vital signs:
Bp : 135|70
O2 : 94%
Temp : 36
HR : 80
S &s :
No new complain but still
complain of fatigability
viral marker by Eliza
manual CBC , uric acid , S, phosphate ,
Urine analysis
TB work up ( sputum AFB , MTB )
flow cytometry
Prepare pt for BMA
Doppler us for left lower limb
Ask about Echo
Increase septrin 960 mg tab to TDS
Ceftriaxone 1 g iv BD
Folic acid OD
Advice:

24. 2
nd
day post admission :
Vital signs :
Bp : 130|60
O2 : 93
Temp :36.6
HR : 85
S &s :
No new complain but still
complain of fatigability
Advice :
Ask about septic work up and TB work up
Ask about LFT , Uric acid , s. Phosphate
Ask about urine analysis and viral marker
by Eliza
RBS chart QID and give insulin according to
scale , don't give if less than 180 mg/ dl
COT .

25. 3 rd. day post admission :
Vital signs :
Bp : 140\90
O2 : 92
Temp :37
HR : 92
S &s :
No new complain but still
complain of fatigability
Advice :
Ask about septic work up and TB work up
Ask about LFT , Uric acid , s. Phosphate, LDH
Ask about urine analysis and viral marker by
Eliza
Change Pantoprazole to tablets
Prepare patient for BMA
Ask about Echo and Flowcytometry
RBS chart QID and give insulin according to
scale , don't give if less than 180 mg/ dl

26. 4 th day post admission :
Vital signs :
Bp : 135\70
O2 : 94
Temp :36.6
HR : 90
S &s :
No new complain but still
complain of fatigability
Advice :
Ask about report of Flowcytometry and
BMA result
Input and output chart
COT.

27. Advice :
Refer patient to oncology center and
follow outpatient clinic
Last day prior to discharge :
Vital signs :
Bp : 120|60
O2 : 93
Temp : 36.9
HR : 95
S &s :
No new complain but still complain of
fatigability

28. Definitive management
The definitive management is chemotherapy so
when the condition was diagnosed we were referred
to the oncology center to receive treatment there

29. Treatment of f AML:
Induction(remission induction)
Standard regimen: “7+3” → Cytarabine (7 days) + Anthracycline (3 days).
Consolidation(post-remission)
High-dose cytarabine (HiDAC) or Allogeneic stem cell transplantation (for high-risk patients).
Targeted therapies :
FLT3 inhibitors (midostaurin, gilteritinib).
IDH1/2 inhibitors (ivosidenib, enasidenib).
BCL-2 inhibitor (venetoclax with hypomethylating agents in unfit patients).
Supportive care :
Blood transfusions, infection prophylaxis/treatment (antibiotics, antifungals), growth factors,
tumor lysis prevention

30. Provisional diagnosis :
Acute myeloid leukemia

31. DDX
Chronic
myeloid
leukemia
Aplastic
anemia
MDS
Metastasis
to bone
marrow
TB
Acute
lymphoblastic
leukemia
lymphoma

32. Review of acute myeloid leukemia

33. AML Management Guidelines (2025) :-

34. Initial Work-Up
Full blood count, bone marrow aspirate/biopsy.
Flow cytometry for lineage.
Cytogenetics + molecular profiling (FLT3, NPM1, IDH1/2, TP53, CEBPA, etc.).

35. Fit Patients (eligible for intensive therapy)
Induction (remission induction):
Standard: “7+3” (cytarabine + anthracycline).
Add targeted drug if mutation present (e.g., FLT3 inhibitor).
Consolidation:
High-dose cytarabine (HiDAC) for favorable risk.
Allogeneic stem cell transplant (allo-SCT) for intermediate/high-risk

36. Unfit / Older Patients (not candidates forintensive chemo)
Preferred: Hypomethylating agent (azacitidine/decitabine) + venetoclax.
Consider adding targeted therapy if mutation present (e.g., IDH1/2 inhibitor,
FLT3 inhibitor)
Supportive care if frail/very poor performance.
.Targeted / Precision Therapy
FLT3+ → midostaurin (frontline with induction) or gilteritinib (relapse).
IDH1+ → ivosidenib.
IDH2+ → enasidenib.
TP53 mutation / complex karyotype → clinical trials preferred.
.

37. Relapsed / Refractory AML
Re-induction with targeted agents ±chemotherapy.
Gilteritinib (FLT3+), IDH inhibitors (IDH+).
Allo-SCT if feasible.
Clinical trials strongly recommended.
.Supportive Care (all patients)
Infection prophylaxis (antibacterial, antifungal, antiviral if indicated).
Blood product support (RBCs, platelets).
Tumor lysis prevention (hydration, allopurinol/rasburicase).
Psychosocial + palliative care integrated as needed

38. Prepared by Dr:| RADFAN YASSIN
اوسنت لا
ا في مكناوخ
ةزغ