A 55 year-old man comes to your office because he is concerned about swollen lymph nodes in his axilla and inguinal regions. He reports, ‘they (swollen lymph nodes) don’t bother me but I am concerned about fever, weight loss and drenching night sweats’. Physical examination reveals painless cervical, axillary, inguinal lymphadenopathy and hepatosplenomegaly. Laboratory tests show elevated LDH levels. An excisional lymph node biopsy revealed back-to-back follicles of the same size, composed of small cells or large cells. Later flow cytometry and genetic tests confirmed the diagnosis as follicular lymphoma. 

A 57 year-old man presents to your primary care office complaining of severe fatigue, night sweats and low-grade fevers for the last four weeks. In the review of systems, he says ‘yes’ to blurred vision and persistent and painful erections. On physical examination, you find tenderness over the sternum. You send him to the laboratory for tests, which reveal the following results: Test Result Normal range Leukocyte count (WBC) 115,000 /mm³ 4500-11,000/mm³ Platelets 640,000 /mm³ 150,000 – 400,000/mm³ Leukocyte Alkaline Phosphatase (LAP) 6 score 20 – 100 Bone marrow: hypercellular, left-shifted myelopoiesis Peripheral smear: multiple immature granulocytes The PCR testing of the peripheral blood and bone marrow detected BCR/ABL gene. Which of the following revolutionized the treatment of this patient’s disorder?

A 58 year-old man presents to your primary care office complaining of severe fatigue, night sweats and low-grade fevers for the last four weeks. In the review of systems, he says ‘yes’ to blurred vision and persistent and painful erections. On physical examination, you find tenderness over the sternum. You send him to the laboratory for tests, which reveal the following results: Test Result Normal range Leukocyte count (WBC) 115,000 /mm³ 4500-11,000/mm³ Platelets 640,000 /mm³ 150,000 – 400,000/mm³ Leukocyte Alkaline Phosphatase (LAP) 6 score 20 – 100 Bone marrow: hypercellular, left-shifted myelopoiesis Peripheral smear: multiple immature granulocytes The PCR testing of the peripheral blood and bone marrow detected BCR/ABL gene. Of the following, which is the most common physical finding in patients with this disorder?

A 54 year-old man presents to your primary care office complaining of severe fatigue, night sweats and low-grade fevers for the last four weeks. In the review of systems, he says ‘yes’ to blurred vision and persistent and painful erections. On physical examination, you find tenderness over the sternum and enlarged spleen. You send him to the laboratory for tests, which reveal the following results: Test Result Normal range Leukocyte count (WBC) 115,000 /mm³ 4500-11,000/mm³ Platelets 640,000 /mm³ 150,000 – 400,000/mm³ Leukocyte Alkaline Phosphatase (LAP) 6 score 20 – 100 Bone marrow: hypercellular, left-shifted myelopoiesis Peripheral smear: multiple immature granulocytes The PCR testing of the peripheral blood and bone marrow detected BCR/ABL gene. Of the following, which is the most likely diagnosis?

A 46 year-old male arrives in the emergency room, complaining of ‘bone pains’, severe weakness and fatigue, easy bruising in the skin, gingival bleeding, nose bleeds, shortness of breath and vision change. On review of systems, you notice continuous headaches and weight loss of over 20 pounds in two months. He was also treated for three episodes of ‘sinusitis’ in the last 2 months. On a physical examination, you notice a thin young man who appears pale, confused and distressed due to dyspnea. His gums are swollen. Other remarkable things are hepatomegaly, lymphadenopathy and tenderness over the sternum, right tibia and left femur. Suspecting a serious underlying disorder, you ordered some laboratory tests. Bone marrow film showed most cells with cytoplasmic reddish-purple granules with several long slender inclusions (as shown in the image), highlighted by peroxidase stain and some lymphocytes are compressed among the cells. This patient was diagnosed with acute promyelocytic leukemia and was initiated on all-trans-retinoic acid (ATRA). After 6 days, he developed fever, shortness of breath, and chest pain. His temperature is 102 °F (38.8°C), heart rate is 108 beats/min, blood pressure is 164/94 mm Hg, respirations are 32 breaths/min, and oxygen saturation is 86% on room air. On examination, the patient is pale and distressful. Lung sounds are abnormal with pleural rub sounds. He has edema in both feet. Chest X showed bilateral pulmonary infiltrates with pleural effusion. Echocardiogram is normal except for pericardial effusions. His laboratory results are given below: Leukocyte count (WBC) 110,000/ mm³ 4500-11,000/mm³ Platelet count 24,000 150,000 – 400,000/mm³ Reticulocyte count 0.5% – 1.5% D-Dimer 900 ng/mL ≤250 ng/mL Partial thromboplastin time (aPTT) (activated) 56 seconds 25-40 seconds Prothrombin time (PT) 18 seconds 11-15 seconds fibrinogen 140 mg/dl 200 – 400 mg/dl fibrin degradation products 22 mcg/ml <10 mcg/ml Erythrocyte count (RBC) 3.2 million/mm³ Male: 4.3 - 5.9 million/mm³ Female: 3.5 - 5.5 million/mm³ proBNP 76 pg/ml < 100 pg/ml Creatinine 0.9 mg/dL 0.6 - 1.2 mg/dL Urea nitrogen 12 mg/dL 7-18 mg/dL Which of the following is the best explanation for the worsening of his condition?

A 44 year-old male arrives in the emergency room, complaining of ‘bone pains’, severe weakness and fatigue, easy bruising in the skin, gingival bleeding, nose bleeds, shortness of breath and vision change.  On review of systems, you notice continuous headaches and weight loss of over 20 pounds in two months. He was also treated for three episodes of ‘sinusitis’ in the last 2 months. On a physical examination, you notice a thin young man who appears pale, confused and distressed due to dyspnea. His gums are swollen. Other remarkable things are hepatomegaly, lymphadenopathy and tenderness over the sternum, right tibia and left femur. Suspecting a serious underlying disorder, you ordered some laboratory tests. Bone marrow film showed most cells with cytoplasmic reddish-purple granules with several long slender inclusions (as shown in the image), highlighted by peroxidase stain and some lymphocytes are compressed among the cells. Patient is diagnosed with acute promyelocytic leukemia.  The acid form of which of the following vitamins is used to treat acute promyelocytic leukemia? 

A 34 year-old male arrives in the emergency room, complaining of ‘bone pains’, severe weakness and fatigue, easy bruising in the skin, gingival bleeding, nose bleeds, shortness of breath and vision change. On review of systems, you notice continuous headaches and weight loss of over 20 pounds in two months. He was also treated for three episodes of ‘sinusitis’ in the last 2 months. On a physical examination, you notice a thin young man who appears pale, confused and distressed due to dyspnea. His gums are swollen. Other remarkable things are hepatomegaly, lymphadenopathy and tenderness over the sternum, right tibia and left femur. Suspecting a serious underlying disorder, you ordered some laboratory tests. Bone marrow film showed most cells with cytoplasmic reddish-purple granules with several long slender inclusions (as shown in the image), highlighted by peroxidase stain and some lymphocytes are compressed among the cells. A Karyogram from the patient demonstrates the translocation of genetic material between chromosomes 15 and 17. What is the most likely diagnosis in this patient?

A 79-year-old man comes to your office and reports weakness, night sweats, and weight loss over the last two weeks. He was diagnosed with chronic lymphocytic leukemia 10 years ago and was managed with only observation. He reported that he was feeling great until these symptoms developed two weeks ago. You knew him well over the years. Compared to his previous visits, he looks more sick. Physical examination reveals bulky, generalized lymphadenopathy. Laboratory tests reveal elevated lymphocytes and elevated lactate dehydrogenase. Positron Emission Tomography shows increased activity with Standardized uptake value of 12. Of the following, expression of which indicates poor prognosis in patients with chronic lymphocytic leukemia ?

A 79-year-old man comes to your office and reports weakness, night sweats, and weight loss over the last two weeks. He was diagnosed with chronic lymphocytic leukemia 10 years ago and was managed with only observation. He reported that he was feeling great until these symptoms developed two weeks ago. You knew him well over the years. Compared to his previous visits, he looks more sick. Physical examination reveals bulky, generalized lymphadenopathy. Laboratory tests reveal elevated lymphocytes and elevated lactate dehydrogenase. Positron Emission Tomography shows increased activity with Standardized uptake value of 12. What is the most likely explanation for the severity of his symptoms?