Case Study: Unexplained Bruises

Karen brings her daughter, Ann into the pediatric clinic stating, "She's just been so tired lately. All she wants to do is sleep and she’s got no appetite. I'm worried." Upon assessment, you discover bruises on the little girls’ arms and legs. Can you can get to the root of Ann's problem?

Updated:  

This article was reviewed and fact-checked by our Editorial Team.
Case Study: Unexplained Bruises

History of Present Illness

Ann is a 6 yo girl who is brought to the pediatric clinic. For the last week, her mother says she has been very tired, lacks energy, sleeps more than usual, and has not had much appetite. Upon assessment, you discover bruises on the little girls' arms and legs that Karen can't explain. She says, "I had no idea those were there!" and looks embarrassed and worried.

Past Medical History

Ann was full-term from an uncomplicated pregnancy and delivery. All immunizations are current. Ann had measles at age 3 yo.

Family History

Ann has one brother, age 8 years, who is in apparent good health. The maternal grandmother died at age 55 from rectal cancer.

Social History

Developmental milestones on target.

Medications

None

Allergies

NKDA

General Appearance

Alert, interactive, pale, height and weight normal for 6-yr-old

Vital Signs

  • BP 108/68
  • HR 130/min
  • RR 20/min
  • T 98.7oF
  • HT 41 inches
  • WT 37 lbs

What are all the possible reasons for these signs and symptoms? Do you remember normal values for pediatrics vital signs? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run?

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety.She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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Can we have some labs please? Particularly CBC with diff and PT/INR.

And do we know anything about dad/paternal family? May not be relevant but still.

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Please could we know: CBC especially Hgb, Hct, platelet count; creatinine; BUN; urinalysis; who Ann lives with; who her primary caregiver/s are; what her normal routine is; who are the people that Ann spends time with or interacts with? Does Ann offer any information about whether she noticed her bruises or how they came about? What was Ann's response when her mother was asked about her bruises?

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Specializes in Education, Informatics, Patient Safety.

You got it! And THANK YOU for reading and commenting.

All vital signs normal except for heart rate, which is tachycardic. Why?

Vital signs:

  • BP 108/68 (normal for 6-year-old)
  • HR 130/min (normal 80-120/min)
  • RR 20/min (normal 20-28/min)
  • T 98.7oF
  • HT 41 inches (normal 41-43 inches)
  • WT 37 lbs (normal 40-50 lbs)

Review of Systems: only abnormal values presented

Skin: very pale, warm, and dry, ecchymosis on extremities, over the buttocks and lower left flank area. No rashes

HEENT: Petechiae of mucous membranes on gums and back of throat, cervical adenopathy, four palpable, non-tender, 2-cm lymph nodes in submaxillary chain

Abd: Liver and spleen enlarged

MS/Ext: Mild adenopathy in inguinal region, bilaterally

Why are the liver and spleen enlarged? Explain the enlarged lymph nodes.

Laboratory Test Results:

  • Hb 7.7 g/dL
  • Hct 23%
  • RBC 2.8 million/mm3
  • WBC 13,100/mm3
  • Neutrophils 59%
  • Lymphocytes 26%
  • Monocytes 3%
  • Eosinophils 1%
  • Basophils 0%
  • Blasts 10%
  • Platelets 29,000/mm3
  • AST 78 IU/L
  • ALT 100 IU/L
  • Total bilirubin 0.8 mg/dL
  • Total protein 6.8 g/dL
  • Alb 3.5 g/dL
  • Ca 9.2 mg/dL
  • Phos 4.0 mg/dL
  • Uric acid 4.2 mg/dL
  • PT 13 sec
  • PTT 25 sec
  • Glucose, fasting 90 mg/dL

Why might AST and ALT be abnormal?

Would you order a spinal tap? If so, why?

What is the patient’s prognosis?

What treatment can you expect?

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Thanks for the update, SafetyNurse!

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Specializes in Education, FP, LNC, Forensics, ED, OB.

? Members are registering their dx guesses in the Help Desk! ?

REMEMBER

Updates are added throughout this CSI. Submit a “dx guess” in the Admin Help Desk.

After an update, if you would like to amend your original guess, return to your ticket to submit additional information.

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Specializes in Education, Informatics, Patient Safety.

And now the moment you've all been waiting for!

Drum roll please......

Laboratory Test Results (with normal values):

  • Hb 7.7 g/dL (12-15.5 g/dL)
  • Hct 23% (35-45%)
  • RBC 2.8 million/mm3 (4.6-6.1)
  • WBC 13,100/mm3 (4,800-10,800)
    • Neutrophils 59% (57-67)
    • Lymphocytes 26% (25-33)
    • Monocytes 3% (3-7)
    • Eosinophils 1% (1-4)
    • Basophils 0% (0.5-1%)
    • Blasts 10% (1-5%)
  • Platelets 29,000/mm3 (150-450,000)
  • AST 78 IU/L (0-35)
  • ALT 100 IU/L (7-56)
  • Total bilirubin 0.8 mg/dL (0.1-1.2)
  • Total protein 6.8 g/dL (6-8)
  • Alb 3.5 g/dL (3.4-4.7)
  • Ca 9.2 mg/dL (8.5-10.5)
  • Phos 4.0 mg/dL (2.5-4.5)
  • Uric acid 4.2 mg/dL (1.4-5.8 in females)
  • PT 13 sec (11-15)
  • PTT 25 sec (25-35)
  • Glucose, fasting 90 mg/dL (60-110)

Course of treatment:

Ann was immediately referred to a pediatric oncologist and admitted to the children’s hospital for workup.

Bone Marrow Aspirate:

93% blasts, 3% erythroblasts, 4% all other cells

RT-PCR (+) for TEL-AML1 fusion gene with no other cytogenetic abnormalities

Chest X-ray:

Normal with no mediastinal mass

Lumbar puncture:

  • Spinal fluid clear and colorless
  • Opening pressure 90 mm H2O
  • Glucose 50 mg/dL
  • Total protein 18 mg/dL
  • No blasts present

Immunology:

(+) for cytoplasmic u heavy-chain proteins

Ann has acute lymphoblastic leukemia (ALL), the most common pediatric cancer. Sixty percent of all ALL cases occur in children, with a peak incidence at age 2 to 5 yr. A high circulating number of blasts, replacement of normal marrow by malignant cells, and the potential for leukemic infiltration of the CNS is caused by malignant transformation and uncontrolled proliferation of an abnormally differentiated, long-lived hematopoietic progenitor cell. Symptoms include fatigue, pallor, infection, bone pain, CNS symptoms (eg, headache), easy bruising, and bleeding. Examination of peripheral blood smear and bone marrow is usually diagnostic. Treatment typically includes combination chemotherapy to achieve remission, intrathecal and systemic chemotherapy and/or corticosteroids for CNS prophylaxis, and sometimes cerebral irradiation for intracerebral leukemic infiltration, consolidation chemotherapy with or without stem cell transplantation, and maintenance chemotherapy for up to 3 yr to avoid relapse. The (+) TEL-AML1 fusion gene is the most common chimeric fusion gene in childhood cancer. It is selectively associated with B cell precursor acute lymphoblastic leukemia.

A lumbar puncture can determine if the leukemia has spread to the cerebral spinal fluid (CSF). Knowing whether or not there is leukemia in the central nervous system helps determine the most appropriate treatment. All children with ALL receive medicine to treat or prevent leukemia of the central nervous system at the same time as the lumbar puncture at specific times during treatment.

Elevated transaminases are common at initial presentation of ALL and are likely due to hepatic injury from leukemic infiltrates. Conjugated hyperbilirubinemia at presentation may require treatment modification and dose reduction. A short course of steroids prior to initiation of induction chemotherapy appears to result in rapid resolution of the hyperbilirubinemia with subsequent ability to provide full dosing of induction chemotherapy.

Treatment:

On the 2nd day following admission, Ann was treated with irradiated/filtered platelets, packed red blood cells and allopurinol (what is the purpose of allopurinol prior to intensive chemo?)

Day 3 remission induction therapy orders

  • Prednisone 1 mg IV q wk x 4
  • Vincristine 1 mg IV q wk x 4
  • Asparaginase 3,600 units on chemotherapy days 3, 6, 9, 13, 16, 20
  • Intrathecal therapy with methotrexate on chemotherapy days 3 and 17

Prognosis:

Younger patients have a better prognosis. This is B-cell ALL, having a lower WBC count (< 30,000) when first diagnosed confers a better diagnosis. Ann had much less than 30,000). Abnormal numbers of chromosomes, abnormal structural changes in a chromosome, or certain molecular genetic changes in the chromosomes of leukemia cells may affect outcome and treatment. Note that the genetic changes referred to here are changes in the genes of the leukemia cells, not the child’s cells – most children with leukemia have completely normal genes.

Response to early treatment:

How well treatment works in the first 1 to 4 weeks of treatment may predict the leukemia’s overall response to treatment. This will be determined by examining the child’s blood or bone marrow regularly. Recent studies have shown that some children may need more intense treatment to improve the chance of a cure. This includes children whose cancer is not responding well to early treatment or those who have high levels of residual leukemia cells (cells remaining after treatment) at the end of remission induction.

References

American Cancer Society, ALL

Merck Manual – Professional Edition

Abnormal liver transaminases and conjugated hyperbilirubinemia in ALL

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Here are the responses from members who came to the Admin Help Desk to submit their diagnoses for the 5th Case Study Investigation (CSI).

CONGRATULATIONS and DOUBLE THUMBS UP to those with the correct FINAL diagnosis!

3/2/20

Susie2310

Quote

?? I haven't had the chance to go through all the labs but from what I can tell the diagnosis looks like Acute Lymphoblastic Leukemia (1st guess)or another type of Leukemia. In Ann's case I understand her prognosis would be good. Treatment is chemotherapy and/or radiation, and sometimes Stem Cell Transfer.

dream'n

Quote

? I'll go and try to answer, but I may be way wrong because I didn't research anything and this is totally off of the top of my head...she needs a bone marrow biopsy. Maybe leukemia?

DextersDisciple

Quote

?? Acute Lymphocytic Leukemia

3/4/20

lsession2

Quote

? Leukemia

NurseBlaq

Quote

:nurse: Answer: Von Willebrand disease

Thank you to all who participated. We hope you enjoyed the CSI.

CSI #6 is coming very soon! ?

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

If you are viewing this for the first time after the answer was posted and didn't post your guess in the Admin Help Desk, did you guess the correct diagnosis?

Educators -

This would be a great exercise to share with your students to sharpen their assessment and diagnostic skills. Please share the link with and encourage your students to see if they get the right diagnosis before they "read the last chapter of the book".

Watch for the next CSI..

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