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Newsletter Vol .4 issue 2 Nov. 2013

                                                                                       Haematology and Oncology Newsletter

Dear friends and seniors,

Hope you have enjoyed your Diwali vacation! We at Lotus wish you all the very best for the coming year. I am glad to share that we at “Lotus” have successfully performed 12 bone marrow transplants till date. The indications included acute leukemia, thalassaemia, aplastic anaemia and multiple myeloma. 

In this issue I will present 2 interesting cases. 

Case 1: 53 yr old male, a welder, resident of bhusaval was referred for refractory anaemia. He complained of weakness and fatigue. No history of blood loss. He first had low Hb,3 years ago. He had blood transfusion once 2 years ago. He had complete workup in Mumbai and then in Pune. A diagnosis of refractory anaemia was made. He was then started on erythropoietin injections. No response was seen after 3 months. He then took homeopathy for 6 months and also oral iron tablets. His Hb was 6.5. MCV and MCH were low. WBC and Platelets were normal when I saw him. 

On examination: he had pallor. No splenomegaly. No other abnormality. USG was normal. 

PBS showed occasional basophilic stippling (these are bluish dots on red cell we see under the microscope). With his refractory anaemia and the fact that he was welder by occupation made me think of lead poisoning. His lead level was 98 (normal range < 20 mcg).

Treatment:   oral treatment with D-Penicillamine in tablet form twice a day was started. One month later his Hb was 7.8 and 3 months later it was 10.7.His treatment was continued for total of 6 months and at the end his Hb was 12.9. 

Take home message:

  1. Detailed history still has a role in super speciality practice and in the era of so called “ advanced medicine”
  2. Refractory anaemia should be looked into seriously and most often we find a cause.
  3. A patient receiving unnecessary blood transfusion should be investigated for his anaemia as an underlying diagnosis can be missed. 

Occupations with increased risk of lead poisoning are:

  1. Radiation shield manufacturers, welders, paint industry, plumbers, construction workers and battery manufacturers etc. 
  2. Few patients can have abdominal pain, neurological symptoms and even infertility. 

Case 2: 58 yrs old male from Malegaon presented to his family physician with 3 months lower back pain. He was given 5 days of tab voveran. He came back in 10 days with same complaints. X ray Lumbar spine was done which shows collapse of T12 vertebral body. He was referred to neuro surgeon. MRI spine confirmed the finding and hence vertebral biopsy was done which showed plasmacytoma.  His blood investigations showed Hb: 7.8, wbc and platelets were normal.  Serum globulins were raised and creatinine was 2.6. He was referred to me for Myeloma and further management. 

Bone marrow done confirmed myeloma. Chemotherapy was started and he completed 4 cycles of chemotherapy with good response. He will undergo bone marrow transplant in Jan 2014. 

What is myeloma?

It is a cancer where plasma cells in bone marrow are increased causing anaemia, renal damage (myeloma “loves” the kidneys!) and bony infiltration. It is a disease of old age and 50% patients present with back pain. Only 3% of patients are below 40 years of age. 

Myeloma has good prognosis if diagnosed early. Autologous bone marrow transplant is a very well established therapy and we have done 2 such transplants on 58 yrs and 63 yrs old myeloma patients. At lotus hospital.

Problems in above case?

  1. Every elderly patient of persistent back pain should be worked up for myeloma.
  2. NSAIDS should be avoided as it increases the chances of renal impairment in myeloma. 
  3. In above case, invasive vertebral biopsy could have been prevented if the CBC was seen and bone marrow was done earlier.
  4. Blood transfusion can be risky in myeloma as it increases the viscosity of blood and cause stroke.

Lotus diagnostics news:

We have now started to do immunodeficiency disease workup. We do serum IgG, IgA and IgM levels important to diagnose patients with immunodeficiency, especially children with recurrent fever and infections. We also do rheumatological test like complement level, anti CCP (for diagnosing rheumatoid arthritis-this test is better than RA factor). We will soon be starting molecular diagnostics division with PCR for acute and chronic leukemia, TB PCR, myeloma etc. 

Funds donated to our registered charity “Junagade Health Foundation” are IT exempted under clause 80G. We have sponsored 6 poor girls with acute lymphoblastic leukemia and given financial help for 21 patients to date. 

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