Janaan health brief case record of the week 1 nov 2016
A 56 years old banker presented to AE with history of being unwell and high temperature for 4 days
He was known to have rheumatoid arthritis for 10 years and was on methotrexate 7.5mg once daily.
Evaluation in AE revealed pancytopenia with HB 60 WCC 0.1 PLT 10, MCV 90
Chemistry was normal apart from CRP of 300
He was commenced on broad spectrum antibiotics with meropemen and fluid resuscitation.
His case was discussed with attending haematologist.
A presumptive diagnosis of methotrexate induced panctopenia and neutropenic sepsis were made.
Folinic acid and GCSF commenced with the hope of count recovery.
The patient was discharged home day 5 with haematology outpatient follow up. He made no haematological recovery week 6 post hospital discharges.
He underwent further blood test to exclude MDS/Aplastic anaemia and all were negative.
He was commenced on transfusion programme and needed 2 weekly blood transfusion and platelets transfusion weekly to keep at a safer level
At week 9 he underwent a bone marrow test
Bone marrow test showed advance myelofibrosis grade 4, no excess of blast and no evidence of gross dysplasia.
Unfortunately the patient became so depressed with all the events and was at some point become suicidal.
Cytogenetics showed – 5q
He was then referred to a specialist in London with special interest on MPD/Myelofibrosis.
HE was commenced on DANAZOLE with no response after 6 weeks.
While he was waiting to get Revlimid he became very sick and was admitted to hospital and died due to overwhelming sepsis despite all the effort including whit cell infusion.
Whether this MF was secondary to methotrexate or a primary event is unknown.
We learn from patient on a daily basis
Co ordinated and timely approach is of paramount importance
Early evaluation and specialist test in selected patient can be invaluable.
Dr Amin Islam, London 4th Nov 2016