Thomas 5 year old boy, Northam

PmHx:

  • Uncomplicated birth
  • reached all developmental milestones at usual ages
  • uncomplicated untreated otitis media 9mo ago

Meds/allergies: none noted;

FHx

  • Rural background
  • recent financial issues
  • Mother, Yvonne D. (PT cleaner at school) brought him in
  • Father recently started work as aerial spraying contractor after 3mo UE

No family history of bleeding disorders

SHx

  • 1st year of school
  • progressing well
  • happy & alert demeanor
  • plays outdoors with friends

Pc

  • Several unexplained nose bleeds
  • unexplained bleeding from gums
  • several bruises to chest & upper arms

Examination:

No signs of trauma/obstruction/infection

Slight pallor, but nails pink

HxPx: Mother suspected abuse by teacher or bully but gums now bleeding

Recent onset bruising

Tender gums; Examination triggers further bleeding

Leg and facial bruising

Signs of recent nosebleeds

Normal chest auscultation; no palpable spleen, liver nor lymph nodes, and normal abdomen palpation

No admission of family/marital discord/abuse

Denies being in contact with father's pesticides

Blood test results

Blood film shows:

  • normal erythrocytes
  • normal neutrophil
  • normal lymphocyte but 2 lymphoblasts present

Blood count:

  • mild normochromic anaemia - mildly elevated total white cells
  • severely reduced platelet count (50,000/mL)

Bone marrow aspiration & CSF examination: acute lympblastic leukemia w/o cerebral involvement

Treatment: Course of chemotherapy over 3 month period at PCH (treatment with methorexate, cyclophoshamide & doxyrubicin) & LT drug therapy over 2 years

Mother has concerns about the impact of doing chemotherapy in Perth on Thomas & rest of family - looking into other options

Treatment progress/effects: suffers nausea, mouth ulceration, vomiting & diarrhoea after 1st treatment

Visible lymphoblasts indicate issue - usual location in bone marrow

Clotting issues with less platelets (hence bleeding)

Doctor to monitor for febrile neutropenia

High turnover of epithelial cells in GI tract -> distension of lumen with fluid (poor absorption) -> nausea