Bloody gum

First pbl session

1.Vital signs of a 15 month old
baby.
2.Define petechiae.
3.Causes of hepatosplenomegaly.
4.Causes of petechiae on upper
limbs.

Petechiae appear when capillaries bleed, leaking blood into the skin

Due to prolonged straining, certain medical conditions, specific types of injuries,

medications, injuries and sunburn
Prolonged straining

Crying

Coughing

Vomiting

Childbirth

Weightlifting
Certain medications

Anticoagulants (warfarin, heparin)

Atropine (Atropen)

Carbamazepine (Carbatrol, Epitol, Tegretol, others)

Infectious diseases
CMV

Hantarvirus pulmonary syndrome

Meningococcemia

Mononucleosis

Rocky Mountain spotted fever

Scarlet fever

Sepsis

Strep throat

Viral haemorrhage fevers

Other medical conditions

Vasculitis

Thrombocytopenia

Leukemia

Scurvy (vitamin C deficiency)

Vitamin K deficiency
Injuries or sunburns

Child abuse involving strangulation or smothering can cause petechiae in the face
and eyes

Biting and spanking

Car crashes

Severe sunburn
5.Causes of lymphadenopathy.
Lymphadenopathy - One or more nodes that are abnormal in either size,
consistency or number. Generalized - lymph nodes enlarged in two or more areas.
Localized - involve only one area.
 Lymph Node Groups: Location, Lymphatic Drainage and Selected Differential Diagnosis

LOCATION LYMPHATIC DRAINAGE CAUSES

Submandibul Tongue, submaxillary gland, lips and Infections of head, neck, sinuses, ears, eyes, scalp, pharynx
ar mouth, conjunctivae

Posterior Scalp and neck, skin of arms and Tuberculosis, lymphoma, head and neck malignancy
cervical pectorals, thorax, cervical and axillary
nodes

Right Mediastinum, lungs, esophagus Lung, retroperitoneal or gastrointestinal cancer

supraclavicul
ar node

Left Thorax, abdomen via thoracic duct Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection
supraclavicul
ar node

Axillary Arm, thoracic wall, breast Infections, cat-scratch disease, lymphoma, breast cancer, silicone implants,
brucellosis, melanoma

Inguinal Penis, scrotum, vulva, vagina, Infections of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection,
perineum, gluteal region, lower syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma,
abdominal wall, lower anal canal pelvic malignancy, bubonic plague
Lymphadenopathy primarily
related to immune response from
infections
VIRAL INFECTIONS : -

● Local/ generalized lymphadenopathy with systemic infections ( infectious

mononucleosis( cervical), rubella (occipital), infectious hepatitis and acquired
immunodeficiency syndrome)

PYOGENIC INFECTIONS :-

● Local enlargement of nodes draining areas of local infection( furuncles

caused by staphylococci and oral infection).

● Local enlargement of nodes draining the portal of entry of infections such as

cat scratch fever, cyptococcosis, lymphogranuloma venereum, primary
chancre of syphilis, and tularemia.

● Generalized lymphadenopathy from ( Salmonella septicemia bacterial

endocarditis, secondary syphilis, and toxoplasmosis.
LYMPHADENOPATHY PRIMARILY FROM INFECTION OF THE NODE BY ORGANISMS:-

● Pyogenic Infection : Pasterurella pestis more common, abscess formation by

staphylococccal invasion.

● Granuloma formation : the entrance of tubercle bacilli/fungi such as

Histoplasma capsulatum , into nodes often results in granuloma formation as
well as hypertrophy, identifiable organisms can be present within granuloma

Neoplasia
Primary neoplastic diseases of nodes : Non-Hodgkin and Hodgkin lymphomas

Metastatic neoplastic processes occuring in nodes.

Lymphoid leukemias : acute myeloid leukemia(granulocytic sarcoma) and chronic

myelogenous leukemia.

Primary myelofibrosis with extramedullary hematopoiesis, producing lymph node

enlargement

Metastases from carcinoma producing lymph node enlargement.

Autoimmune diseases (systemic lupus
erythematosus, rheumatoid arthritis, Sjogren syndrome, and Hashimoto
thyroiditis)

Reaction to Drugs : Hydantoins.

Dermatopathic related to skin diseases

Miscellaneous diseases:-
● Granuloma formation as seen with sarcoid / in patients exposed to berrylium

● Reactive hyperplasia as seen in hyperthyroidism

● Progressive transformation of germinal centers

● Kikuchi-Fujimoto disease( histocytic necrotizing lymphadenitis)

● Kawasaki disease
6.Normal range of blast cells.
7.What diseases cause blast cells
to be in circulation?
8.Differences between acute and
chronic leukemia.
9.Classification of leukemia.
10. Aetiology of Acute
lymphoblastic leukaemia
(Medscape)
•Less is known about the etiology of acute lymphoblastic leukemia (ALL) in adults
compared with acute myelogenous leukemia (AML). Most adults with ALL have no
identifiable risk factors.
•Although most leukemias occurring after exposure to radiation are AML rather than
ALL, an increased prevalence of ALL was noted in survivors of the Hiroshima atomic
bomb but not in those who survived the Nagasaki atomic bomb.
•Rare patients have an antecedent hematologic disorder (AHD) such as
myelodysplastic syndrome (MDS) that evolves to ALL. However, most patients with
MDS that evolves to acute leukemia develop AML rather than ALL. Similarly, a small
number of patients receiving lenalidomide as maintenance therapy for multiple
myeloma have developed secondary ALL.
Pathophysiology of ALL
(mayoclinic)
•Acute lymphocytic leukemia occurs when a bone marrow cell develops
errors in its DNA. The errors tell the cell to continue growing and dividing,
when a healthy cell would normally stop dividing and eventually die.
•When this happens, blood cell production becomes abnormal.
•The bone marrow produces immature cells that develop into leukemic
white blood cells called lymphoblasts.
•These abnormal cells are unable to function properly, and they can build up
and crowd out healthy cells.
•It's not clear what causes the DNA mutations that can lead to acute
lymphocytic leukemia. But doctors have found that most cases of acute
lymphocytic leukemia aren't inherited.
Pathogenesis of ALL
•The pathogenesis is varied. Certain germline polymorphism in a group of genes
mainly involved in B- cell development (e.g. IKZF1) are more frequent in patients with
B- cell ALL (B- A LL) than controls.
•Interestingly, IKZF1 is also deleted in the leukaemic cells in 30% of high risk B- A LL
and 95% of ALL BCR - ABL1 positive cases.
•In a proportion of cases the first event occurs in the fetus in utero, with a secondary
event possibly precipitated by infection in childhood.
•The first event is a translocation (e.g. t(12; 21)) or point mutation.
•The second event involves genome - wide copy number alterations, some of which
encode for functions relevant to leukaemogenesis.
•In other cases, the disease seems to arise as a postnatal mutation in an early
lymphoid progenitor cell
Risk factors of ALL
Factors that may increase the risk of acute lymphocytic leukemia include:

•Previous cancer treatment. Children and adults who've had certain types of
chemotherapy and radiation therapy for other kinds of cancer may have an increased
risk of developing acute lymphocytic leukemia.
•Exposure to radiation. People exposed to very high levels of radiation, such as
survivors of a nuclear reactor accident, have an increased risk of developing acute
lymphocytic leukemia.
•Genetic disorders. Certain genetic disorders, such as Down syndrome, are
associated with an increased risk of acute lymphocytic leukemia.
•Having a brother or sister with ALL. People who have a sibling, including a twin,
with acute lymphocytic leukemia have an increased risk of ALL.
11.Clinical features of leukemia.
12.Complications of leukemia.
1.Infection
2.Bleeding
3.Infertility
4.Side effects of chemotherapy and stem

cell transplantation (treatment)

Infection
-weakened immune system--common complication of leukaemia.
-weakened immune system--immunocompromised.
-patients--take regular doses of antibiotics--prevent infections.
-symptoms of infection include:
o fever of 38°C (100.4F) or above
o headache
o aching muscles
o diarrhoea
o tiredness
Bleeding
-bleed and bruise more easily--low levels of platelets in blood.
-Bleeding--excessive.
-Bleeding can occur:
o inside the skull (intracranial haemorrhage)
o inside the lungs (pulmonary haemorrhage)
o inside the stomach (gastrointestinal haemorrhage)
The symptoms of an intracranial haemorrhage include:

o severe headache

o stiff neck

o vomiting
o change in mental state, such as confusion
The common symptoms of a pulmonary haemorrhage are:
o coughing up blood from nose and mouth
o breathing difficulties
o a bluish skin tone (cyanosis)
The common symptoms of a gastrointestinal haemorrhage are:
o vomiting blood
o passing stools (faeces) that are very dark or tar-like
infertility
-Treatments--cause infertility.
-Infertility--temporary--in some cases--permanent.
-People--received high doses of chemotherapy and radiotherapy for bone
marrow or stem cell transplantation--at risk--infertile.
Side effects of chemotherapy and stem cell
transplantation
-low blood cell counts

-infection

-Graft versus host disease (GVHD)

-Tumor Lysis Syndrome (TLS)

-hyperglycemia, steroid-induced diabetes and gastric ulcers

-mucositis

-organ toxicity
 13.Treatment and management of
leukemia.
STAGES OF TREATMENT

● Induction - to kill the leukemia cells in the bone marrow, restore balance of cells in blood,
resolve symptoms

● Consolidation - to kill remaining leukemia cells in CNS

● Maintenance - taking regular doses chemo tablets to prevent leukemia returning

INDUCTION

❏ May need regular blood transfusions

❏ Sterile environment

❏ Chemotherapy - to kill leukemia cells in bone marrow

- Some chemo directly administered into CSF - nervous system and brain - methotrexate -
- Side effects of chemo :

● Vomiting

● Diarrhoea

● Loss of appetite

● Nausea

● Tiredness

● Mouth ulcers

● Infertility

● Hair loss

● Skin rashes

❏ Steroid Therapy - corticosteroid, to improve effectiveness

CONSOLIDATION

- To ensure remaining leukemia cells are killed

- Receiving regular chemo on an outpatient basis

- Several months

MAINTENANCE

- To act as further insurance against the possibility of leukemia returning

- Less toxic and easier to tolerate

- Can last for 2 years

Other :

RADIOTHERAPY : 2 situations

- Treat advanced ALL that have spread to NS/brain

- Prepare body for bone marrow transplant

14.Psychosocial impact and
breaking bad news.