CASE STUDY

35-year-old Esther presented to her General Practitioner after experiencing two-months of spontaneous bruising to her body without any known injuries, bleeding gums, persistent fatigue, and sore throat. Esther was a recent first-time mother (9-month-old) and thought that these changes were considered normal. Her general practitioner arranged pathology to take a peripheral full blood count (FBC) which showed the following:

Haemoglobin: 75g/L (ref. range 120 – 150g/L)

WCC: 20 (x 10/L) (ref. range 3.5 – 11 (x10/L))

Neutrophils: 0.8 (x 10/L) (ref. range 1.7 – 7.0 (x10/L))

Platelets: 32 mcL (ref. range 150 – 450 (x10/L))

Blasts %: 50% (ref. range <5%)

Esther’s diagnosis

Normal blood smear

AML blood smear

On receipt of the results, the general practitioner rang the haematologist on call at the local healthcare facility. Esther was contacted and told to attend the emergency department for further testing. On arrival to department Esther was met by the haematologist who took her straight to the oncology ward. A physical examination was undertaken, and the haematologist told her that her presentation indicated Acute Myeloid Leukaemia (AML). A bone marrow biopsy was arranged for the next day with the blood smear from this showing 80% blasts cells in the bone marrow; her diagnosis of AML was confirmed.

An intervention

Esther had a Hickman’s line (Central Venous Access Device- refer to image) placed in her chest, was provided with blood cell support (PRBC’s and platelets) and was to begin a high dose chemotherapy induction (7-3 : Cytarabine and DAUNOrubicin) two days following her initial presentation.

Complications

Oral Mucositis in Cancer Patients

On day +6 of her treatment her blood results that morning showed:

Haemoglobin: 82g/L (ref. range 120 – 150g/L)

WCC: 8 (x 10/L) (ref. range 3.5 – 11 (x10/L))

Neutrophils: 0.01 (x 10L) (ref. range 1.7 – 7.0 (x10/L))

Platelets: 10 mcL (ref. range 150 – 450 (x10/L))

At 0800 hours, Esther rang the call bell complaining of a sore mouth and difficulty swallowing due to pain. On observation her mouth was filled with new ulcers, her gums were bleeding and mouth/lips dry indicating severe oral mucositis (refer to image). She was provided with mouth care and a stat dose of oral morphine (ordine) 2mg was given.

Deterioration

On a routine observation round at 1000 hours Esther was observed to be diaphoretic, she had an increased work of breathing (WOB), was rigoring (shaking) and pallor. Her vital signs were taken and were as follows:

23/02/20: 1005 hours

Heart rate             123bpm

Blood pressure     100/53mmHg

Respiratory rate     24/m

Temperature     39.2

SaO2                     94%