Things not to miss - Acute leukemia

A young girl admitted with a history of low-grade fever for 3 days duration during a dengue epidemic. She was otherwise well. There were no other physical features on examination.

She was managed as a dengue fever with oral fluids. Her initial FBC showed WBC 4.3 and PLT 88. On day 6 her WBC was 4.6 with PLT 95. As she was afebrile for 2 days she was discharged with a plan to review in 3 days. 

She returned 3 days later with another FBC. WBC was 4.4 and PLT was 112. As the platelets were rising the plan was to review her SOS.

Two weeks later she admitted with fever to the same ward.

By that time her FBC was drastically different.

WBC - 1.2
Hb - 9.5
PLT - 6

Further investigations revealed that she had got acute lymphocytic leukemia.

Lesson
  • Especially in young patients, consider all abnormal investigations to be a serious disease unless proven otherwise.
  • Whenever you detect an abnormal report at the time of discharge make sure to review the patient with another report later.
  • Don’t get falsely reassured by a rising trend as in this patient.
  • In dengue following resolution, platelets very rapidly become normalized or even shoot up above normal values. A persistently low value indicates some other complication. In most of the patients, it’ll be ITP. But in some rare instances, it may end up with serious illnesses like leukemia or hemophagocytic lymphohistiocytosis.
Two things that you should never miss in a patient with viral fever-like illness
  • Splenomegaly
  • Lymphadenopathy
What are the other physical features you will look for?

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