Oncology Case Challenge: A 46-Year-Old Mother With Severe, Constant Abdominal Pain

Mounika Gangireddy, MD, MBBS

Disclosures

April 13, 2022

Physical Examination and Workup

Upon physical examination, the patient appears to be in moderate distress. Her heart rate is 110 beats/min, her respiration rate is 20 breaths/min, and her oxygen saturation level is 95% on room air. She is afebrile. Her head appears normal and shows no trauma. Her abdomen is soft and diffusely tender to palpation in all four quadrants. No lymphadenopathy or hepatosplenomegaly is noted. Her lungs are clear to auscultation, and S1 and S2 heart sounds are audible.

Laboratory studies reveal these values:

  • White blood cell (WBC) count: 7800 cells/µL, with 61% neutrophils, 8% basophils (reference range, 3800-10,500 cells/µL, with 55%-70% neutrophils, 0.5%-1% basophils)

  • Hemoglobin level: 9.6 g/dL (reference range, 11.8-15.7 g/dL)

  • Platelet count: 3,056,000 cells/µL (reference range, 150,000-369,000 cells/µL)

  • International normalized ratio: 0.97 (reference range, < 1.1)

  • Partial thromboplastin time: 24.3 sec (reference range, 60-70 sec)

  • Lactate dehydrogenase level: 235 U/L (reference range, 140-280 U/L)

  • Iron saturation and ferritin level: 8% (reference range, 15%-45%) and 8 ng/mL (reference range, 11-250 ng/mL), respectively

  • Folate level: 15.4 ng/mL (reference range, > 5.8 ng/mL)

  • Vitamin B12 level: 352 pg/mL (reference range, 180-914 pg/mL)

  • Sodium level: 138 mmol/L (reference range, 135-145 mmol/L)

  • Potassium level: 4.5 mmol/L (reference range, 3.6-5.2 mmol/L)

  • Chloride level: 107 mmol/L (reference range, 96-106 mmol/L)

  • Blood urea nitrogen level: 10 mg/dL (reference range, 6-24 mg/dL)

  • Creatinine level: 1.1 mg/dL (reference range, 0.6-1.2 mg/dL)

  • Alkaline phosphatase level: 65 IU/L (reference range, 44-147 IU/L)

  • Alanine aminotransferase level: 19 IU/L (reference range, 4-36 IU/L)

  • Aspartate aminotransferase level: 32 U/L (reference range, 8-33 U/L)

  • Total bilirubin level: 0.8 mg/dL (reference range, 0.1-1.2 mg/dL)

Flow cytometry reveals no evidence of immunophenotypically abnormal T or B cells.

A CT of the abdomen and pelvis shows hemorrhagic products in the left pelvic region, likely secondary to a ruptured ovarian cyst. No active extravasation of dye is noted.

The peripheral blood smear reveals thrombocytosis and polychromatophilic red cells with circulating blasts (Figures 1 and 2). Examination of the bone marrow shows hypercellular marrow with increased megakaryocytes (Figures 3 and 4).

Figure 1.

Figure 2.

Figure 3.

Figure 4.

The results of bone marrow cytogenetic analysis are positive for t(9;22). A review of outside records shows that the patient had an elevated platelet count of approximately 900,000 cells/µL several years prior to the current presentation. The elevation was thought to be reactive from her known iron deficiency. She was lost to follow-up.

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