Case 151 – The Begining

It is a friday afternoon and as the haematology registrar who has had a busy on call, the weekend looks quite inviting. The phone rings and it is the Paediatric SHO.

There is a 7 month old boy who has presented to the A & E. He has been irritable for the past week and has not been feeding well. He also has been reviewed by the GP for fever. A 5 day course of amoxycillin has not helped. Mum feels he is becoming more lethargic and poorly.

He was born at term. Sailed through his neonatal period with no concerns. Has been immunised till date and has remained well till now. Growing well and all the developmental milestones are appropriate for his age. He has one elder sibling and she is well.

The Paediatric SHO examines him and finds that he has palpable cervical and inguinal lymph nodes and some rashes. There is a 6cm palpable spleen and a 4cm palpable liver. A few scattered crepts on auscultation of the chest. No bleeding manifestations or jaundice was reported.

Promptly a chest Xray has been performed and everything is fine. Bloods show:

Hb 69 g/L
Plt 28 x10^9/L
WCC 42.47 x10^9/L
Neutrophils 6.85 x10^9/L
Lymphocytes 25.06 x10^9/L
Monocytes 4.25 x10^9/L
Eosinophils 0.5 x10^9/L
Basophils 1.7 x10^9/L

CRP is 11 and biochemistry is normal.

Urine and blood cultures are awaited .

You request the lab to do a blood film on him and this shows leucoerythroblastic blood picture with lymphocytosis , monocytosis and 1-2% suspicious atypical cells – likely blasts. There is true thrombocytopenia.

But the SHO is worried about the blood results and wants to know what to do next? What are the possibilities at this point ? What other tests would you request? Would you do a bone marrow ?

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