Admitted on 10-2-72 to National Cancer Institute, Hematology and Supportive Care Branch Expired on 11-15-72 from National Cancer Institute, Hematology and Supportive Care Branch HOSPITAL COURSE: Problem No. 1 = Acute Proganulocytic Leukemia: On the morning of the second hospital day the patient had a posterior iliac crest bone marrow aspirate revealing decreased normal marrow elements and infiltration by cells with prominent eosinophilic cytoplasmic granules and prominent nucleoli. Some of these cells had Auer rods in the cytoplasm. The impression was that the marrow showed changes of acute promyelocytic leukemia. A bone marrow biopsy showed hypercellularity and infiltration by abnormal cells. Despite extensive marrow involvement, however, the patient did not have severe anemia or circulating abnormal cells when he first presented here. On October 12 he was discharged, feeling well, to be followed closely in the Special Ambulatory Care Clinic. The plan was to trest him for bleeding episodes, the appearance of blast cells in the peripheral blood, splenomegaly, or deterioration of coagulation parameters. Unfortunately, after only two days in the Outpatient Clinic, the patient's platelet count fell to 7,000, and he developed an earache and ahd a low-grade fever. He was therefore readmitted and on October 15 begun on therapy with cytosine arabinoside, 100 ng. per meter squared intravenously every 12 hours, and 6-thioguanine, 90 mg. per meter squared orally every 12 hours. The patient's base-line prothrobin time, partial thromboplastin time, thrombin time, fibrinogen, fibrin split products, and factor VIII were within the normal range; nevertheless, because of the association of intravascular coagulation with acute progranulocytic leukemia, he was treated prophylactically with heparin, 0.5 mg. per kg. intravenously every 6 hours for the first five days of chemotherapeutic drugs. On the first day of treatment the white blood count was 1,700 with 21% neutrophils, 56% lymphocytes and 20% abnormal precursors; platelets were 32,000 (after transfusion) and hemoglobin 10.3. His white count remained low throughout the remainder of his hosital course; abnormal forms disappeared from the peripheral blood on the ninth day of treatment; platelet transfusions were administered every two or three days in an effort to keep the platelet count above 20,000. Serial bone marrow examinations revealed: on day five, hypercellular marrow with 80% abnormal cells; on day seven, hypercellular marrow with 90% progranulocytes; on day twelve, hypercellular marrow with 95% progranulocytes; on day fourteen, hypercellular marrow with 82% progranulocytes; on day nineteen, normocellular marrow with 80% progranulocytes; on the day prior to death, after twenty-two days of treatment, a hypocellular marrow with persisting foci of abnormal promyelocytes. On the day prior to death the patient's hemoglobin was 8.3, white cell count, 2,100 with 100% lymphocytes, and platelet count 11,000. He had received 10 units of packed red blood cells and had received platelet transfusions on 18 days of his hospital stay. During the last two weeks of life he had very poor increments in platelet count after platelet transfusions, probably because HLA identical platelets were not available for transfusion. Rongelap (54) CLINICAL RECORD 09-44-40 3 0 Hinery ond Physce! Examination PR Sommer Narrative -4THE CUNICAL CENTER NATIONAL INSTITUTES OF HEALTH 143 | C1 Consultation CT fetlowup Continuation NIH-PPP (Rev. 5-71)