Dear Seniors and Colleagues,
We are eagerly awaiting the arrival of monsoon so that our drinking water problems are solved and also to take the much awaited monsoon break. Before we do that few interesting cases which makes us think” yes, medicine is indeed an art”. I take this opportunity to thank each one of you for your continued support to our lotus hospital, which celebrated its second year of existence recently with a programme named “ rakta Sadhana” and this years theme was “thalassaemia mukta bharat”
Case 1: referred by Dr Deepak Avhad, Paediatrician, Sinnar.
4 year old male child developed cervical lymphadenopathy. He was given 5 days of oral antibiotics with no effect. The patient’s father decided to see a surgeon. O examination he also had axillary lymphadenopathy. He had mild fever. Hb: 11.0 wbc: 18,200 and platelets: 1,20,000. He underwent a cervical LN biopsy. Local report was inconclusive(after 6 days) so it was sent to a referral lab in Mumbai and then final report came as Lymphoblastic Lymphoma (after 19 days of biopsy). When he was referred to our clinic his counts were Hb: 9.9 wbc: 67,400 and platelets: 34,000. He was urgently started on childhood lymphoblastic lymphoma/leukemia chemotherapy protocol. He also had right testicular swelling at the time he saw me. He went into remission on day 26 post chemotherapy.
Problems in the case?
- This child had high risk disease when he presented to us as he had wbc> 50,000, testicular involvement. His overall prognosis is much worse now.
What could have been done?
- At initial presentation, the high wbc count should have been seen more closely (PBS examination) and there would have been blasts at that stage. We would have done a bone marrow at that stage (avoiding a lymph node biopsy) with diagnosis in 6 hours! It took 19 days in this case and the child’s disease had progressed to high risk stage by the time treatment was started.
Effects of late diagnosis?
1.He will need more intensive chemotherapy for his high risk disease and of course more money!
2.He will have more acute and chronic chemotherapy related side-effects. His risk of disease relapse is also high due to the testicular involvement.
Take home messages?
- Lymphadenopathy to be taken seriously.
- Detailed PBS (peripheral blood smear) examination in each case of lymphadenopathy.
- Preference to be given to less invasive ways of diagnosis.
- All specialities to work together for the common good of the patients rather than “ my patient” attitude.
Vitamin B12 deficiency: I saw 2 patients recently:
platelets Vitamin B12 (NR: 180-911)
7 month male child
98,000 0.0 only! (double checked)
3 month female child
1,32,000 2.3 only! (double checked)
All other anaemia investigation workup was normal. Both were born by normal delivery to pure vegetarian mothers. Case 1 mother had VitB12 of 98.5 only (normal range (180-911). Case 2 mother not tested.
Our traditional teaching is that nutritional deficiency is not seen before 6 months of age as maternal nutrients are enough. This may be true for western mothers who have non vegetarian diet! Indian mothers are anaemic more often during pregnancy and hence the increased risk of nutritional deficiency.
- We all know the importance of Vit B12 and Folate in neurological development. First 2 years of neurological development are more important.
- If we avoid this deficiency INDIA will be “real super power” in next 20 years due to intellectual supremacy!!!
“Junagade Health Foundation” is a registered charity which helps poor patients with blood cancer and other blood diseases like thalassaemia. Todate we have adopted 4 girls (all between 1-12 years of age) of acute lymphoblastic leukemia through our foundation. Our foundation specifically helps female children as I have realized that they are often neglected when it comes to blood cancer (though there is 80% cure today) as the parents are worried about long term side effects especially the ability to start a family.