Case 13: What's Black and White and Green All Over?

Presenter: John F. de Groot, MDMentor: Jana Portnow, MD

Disclosures

June 18, 2002

Introduction & Case Presentation

Introduction

A 58-year-old woman who underwent bone-marrow transplant for acute myelogenous leukemia (AML) presents with the sudden onset of memory loss and confusion.

Case Presentation

Eighteen months earlier the previously healthy patient began to notice easy bruising and bleeding, and subsequently was found to have a white blood cell count of 78,000 cells/mcL. Results of a bone marrow study were consistent with M1 AML. She was treated with cytarabine, daunorubicin, and etoposide induction chemotherapy and achieved complete remission. Her treatment course was complicated by the development of a perirectal abscess and Clostridium difficile colitis. Seven months later the AML recurred. The patient was treated with mitoxantrone, etoposide, and cytarabine, and achieved a second remission. During this course of chemotherapy, the patient developed a fever and shortness of breath; a chest x-ray revealed bilateral nodular pulmonary infiltrates. She received a prolonged course of IV amphotericin B for presumptive pulmonary aspergillosis. A head CT and cerebrospinal fluid cultures were negative for evidence of CNS aspergillosis. A transesophageal echocardiogram was also within normal limits. Three months later the patient received a nonmyeloablative allogenic bone marrow transplant (BMT) from a haploidentical sibling donor. Graft-vs-host disease (GVHD) clinical grade 2 was treated with mycophenolate mofetil and prednisone, followed by FK506 for continued immunosuppression. A subsequent bone marrow biopsy/aspirate was negative for residual leukemia.

Since the time of her BMT the patient has complained of mild short-term memory loss. Two days before the current admission the patient's daughter noted that she became acutely confused with worsening short-term memory. Her oncologist discontinued the FK506 without improvement in her mental status. She was seen urgently in clinic where she was found to be disoriented to time and place, and forgetful of directed tasks within minutes. She scored 19/30 on the mini mental status exam (MMSE). Nonetheless, the patient stated that she was "doing well" and denied any problems. She was admitted to the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital for further evaluation.

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