v**5
发帖数: 745 | 1 母亲70岁，今年秋天体检查出异常，后被诊断为胸腺瘤，10月初接受手术切除左胸腺，
上周洗澡后偶尔发现双小腿出现大面积的小出血点，后被搓澡的地方也出现很多小出血
点和瘀斑，查血发现血小板低，淋巴细胞百分比非常高，血红蛋白，红细胞、中性粒细
胞偏低，白血球正常，全身淋巴B超未发现异常，现在北京住院检查，还没有确诊，请
教各位帮着看看可能是什么病，非常非常感谢！ |
V**D
发帖数: 2869 | |
b**h
发帖数: 293 | 3 可能是病毒感染引起的血小板降低。属于ITP。
因为淋巴细胞增高，不能排除CLL。5% CLL会出现ITP。
需要骨髓穿刺来排除CLL。
目前需要上大剂量激素来控制血小板进一步下降。 |
v**5
发帖数: 745 | 4 多谢两位的解答。
ITP-免疫血小板过低紫斑症
CLL-慢性淋巴细胞白血病
我会根据母亲的各项检查结果再作更新。
【在 b**h 的大作中提到】
: 可能是病毒感染引起的血小板降低。属于ITP。
: 因为淋巴细胞增高，不能排除CLL。5% CLL会出现ITP。
: 需要骨髓穿刺来排除CLL。
: 目前需要上大剂量激素来控制血小板进一步下降。
|
l*h
发帖数: 4124 | 5 this is too little information. basically she needs a spontaneous hemorrhage
workup before any judgment can be done.
【在 v**5 的大作中提到】
: 母亲70岁，今年秋天体检查出异常，后被诊断为胸腺瘤，10月初接受手术切除左胸腺，
: 上周洗澡后偶尔发现双小腿出现大面积的小出血点，后被搓澡的地方也出现很多小出血
: 点和瘀斑，查血发现血小板低，淋巴细胞百分比非常高，血红蛋白，红细胞、中性粒细
: 胞偏低，白血球正常，全身淋巴B超未发现异常，现在北京住院检查，还没有确诊，请
: 教各位帮着看看可能是什么病，非常非常感谢！
|
v**5
发帖数: 745 | 6 So far these are what I got, I would update it after I get more
test results. And would you pls explain what is a spontaneous hemorrhage
workup? Thank you!
hemorrhage
【在 l*h 的大作中提到】
: this is too little information. basically she needs a spontaneous hemorrhage
: workup before any judgment can be done.
|
v**5
发帖数: 745 | 7 更新一下母亲的病情，请大家帮忙看看！
骨穿（形态学），结果正常。抗ENA抗体，抗核抗体，结果正常。
这几天的血小板持续下降，最差下降至数千，输血小板后上升到5-6W，但是输完后仍
持续下降，今天已下降到3W。
医生目前还没有任何解释，怀疑是单纯红细胞再生障碍（PRCA），但是这无法解释
目前最令人担心的血小板异常。还怀疑有可能是淋巴瘤，刚做了PET-CT，目前
还在等待结果。
【在 v**5 的大作中提到】
: So far these are what I got, I would update it after I get more
: test results. And would you pls explain what is a spontaneous hemorrhage
: workup? Thank you!
:
: hemorrhage
|
l*h
发帖数: 4124 | 8 if platelet count drops fast after transfusion, there is something attacking
platelets, most commonly autoimmune mechanisms. this could be ITP, could
also be a part of other know autoimmune diseases.
if you could, post a description of the events in chronological order. also
post all tests that have been done. at least you should have peripheral
blood smear, CBC and CMP results. post detailed results, not your own
interpretation.
【在 v**5 的大作中提到】
: 更新一下母亲的病情，请大家帮忙看看！
: 骨穿（形态学），结果正常。抗ENA抗体，抗核抗体，结果正常。
: 这几天的血小板持续下降，最差下降至数千，输血小板后上升到5-6W，但是输完后仍
: 持续下降，今天已下降到3W。
: 医生目前还没有任何解释，怀疑是单纯红细胞再生障碍（PRCA），但是这无法解释
: 目前最令人担心的血小板异常。还怀疑有可能是淋巴瘤，刚做了PET-CT，目前
: 还在等待结果。
|
b**h
发帖数: 293 | 9 列上用药史。
超声查过肝脾大小没有？
报上骨穿病理结果。
別忘了感染：病毒，Erlichiosis。
报上PT, PTT 结果。
血涂片结果，尤其是否有schistocyte
当下按ITP治。上激素。不到万不得已不要输血小板。
【在 v**5 的大作中提到】
: 更新一下母亲的病情，请大家帮忙看看！
: 骨穿（形态学），结果正常。抗ENA抗体，抗核抗体，结果正常。
: 这几天的血小板持续下降，最差下降至数千，输血小板后上升到5-6W，但是输完后仍
: 持续下降，今天已下降到3W。
: 医生目前还没有任何解释，怀疑是单纯红细胞再生障碍（PRCA），但是这无法解释
: 目前最令人担心的血小板异常。还怀疑有可能是淋巴瘤，刚做了PET-CT，目前
: 还在等待结果。
|
v**5
发帖数: 745 | 10 我还没有回北京，周末会让家里人把能拿到手的具体结果告诉我，然后贴上来。
PET-CT查体内淋巴，未发现异常。
肝脾大小正常。
血小板抗体 阴性
北医三院到现在也拿不出治疗建议，未来不排除需要转院，请教各位北京哪些医院治疗
ITP是比较有经验的？
【在 b**h 的大作中提到】
: 列上用药史。
: 超声查过肝脾大小没有？
: 报上骨穿病理结果。
: 別忘了感染：病毒，Erlichiosis。
: 报上PT, PTT 结果。
: 血涂片结果，尤其是否有schistocyte
: 当下按ITP治。上激素。不到万不得已不要输血小板。
|
|
|
f****o
发帖数: 2770 | 11 ITP不管医院有没有经验
prednisone先来啊
这个病没有根治的本来就是idiopathic
Prednisone最便宜了
不管用就IVIG了
Rituximab
Nplate/Promacta国内能不能弄到呢 |
b**h
发帖数: 293 | 12 如需要，可要求人民医院或协和医院的血液内科会诊。
【在 v**5 的大作中提到】
: 我还没有回北京，周末会让家里人把能拿到手的具体结果告诉我，然后贴上来。
: PET-CT查体内淋巴，未发现异常。
: 肝脾大小正常。
: 血小板抗体 阴性
: 北医三院到现在也拿不出治疗建议，未来不排除需要转院，请教各位北京哪些医院治疗
: ITP是比较有经验的？
|
v**5
发帖数: 745 | 13 附上部分血检结果，excel表贴上来会乱做一团，只好弄成图片，字小只能委屈各位了
，万分感谢！ |
l*h
发帖数: 4124 | 14 I would give myelodysplastic syndrome a serious consideration, pending
further results, especially peripheral blood cell morphology and bone marrow
aspiration.
【在 v**5 的大作中提到】
: 附上部分血检结果，excel表贴上来会乱做一团，只好弄成图片，字小只能委屈各位了
: ，万分感谢！
|
b**h
发帖数: 293 | 15 从血象上来看，最象 CLL。
不象MDS。
【在 v**5 的大作中提到】
: 附上部分血检结果，excel表贴上来会乱做一团，只好弄成图片，字小只能委屈各位了
: ，万分感谢！
|
v**5
发帖数: 745 | 16 衷心感谢两位的意见，看来情况很不乐观，已准备尽快回北京。
外周血细胞形态学、骨髓穿刺及其他可以拿到的检查结果估计可以在周三左右贴上来。
另外补充个情况，11月初手术后复查显示左胸腔有1.9cm积液，最近的检查显示积液
可能有所增加。
【在 b**h 的大作中提到】
: 从血象上来看，最象 CLL。
: 不象MDS。
|
v**5
发帖数: 745 | 17 骨髓穿刺活检病理报告（Nov 20 2012）
骨髓穿刺组织腔内以脂肪髓为主，造血细胞明显减少：髓系和红系均明显减少，未见巨
核细胞，浆细胞散在增生，请结合临床除外再生障碍性贫血（AA）。
免疫组化结果
CD138(+), CD20(个别+), CD235a(+), CD3(散在+)， CDb1(-1), MPO(+)
目前北医三院初步认为是再生障碍性贫血（AA）。各位是否有不同的诊断？该病该如何
治疗？谢谢！
5cm。
【在 v**5 的大作中提到】
: 衷心感谢两位的意见，看来情况很不乐观，已准备尽快回北京。
: 外周血细胞形态学、骨髓穿刺及其他可以拿到的检查结果估计可以在周三左右贴上来。
: 另外补充个情况，11月初手术后复查显示左胸腔有1.9cm积液，最近的检查显示积液
: 可能有所增加。
|
l*h
发帖数: 4124 | 18 you are right in that peripheral count itself looks more like CLL. but her
lymph nodes seemed normal. i also considered she is already in the
hematology department in a big hospital. if it were CLL, it would be late
stage, that would say her current docs and those treated her in Oct were all
unable to recognize the most common leukemia.
MDS with a proliferative or reactive element can explain her clinical
presentation.
that being said, i could be wrong.
【在 b**h 的大作中提到】
: 从血象上来看，最象 CLL。
: 不象MDS。
|
l*h
发帖数: 4124 | 19 the main differential would be hypocellular MDS.
it could be quite difficult to distinguish these two in some patients.
basically, in AA, blood stem cells are decreased in number but their
functions are normal; in MDS, the number can be either normal or decreased,
but their functions are abnormal. as a result, in AA, the morphology of
peripheral blood cells is normal; in MDS, some cells have abnormal
morphology and may be destroyed prematurely.
AA usually occurs in children and young adults; MDS usually occurs in the
elderly. in AA, usually the erythrocytic (red blood cells) lineage is the
most severely suppressed; in MDS, it could be myeloplastic or megakaryocytic
lineage that is the most severely suppressed.
you can search for aplastic anemia vs. myelodysplastic syndrome. there are
some reviews discussing how to differentiate in difficult cases.
【在 v**5 的大作中提到】
: 骨髓穿刺活检病理报告（Nov 20 2012）
: 骨髓穿刺组织腔内以脂肪髓为主，造血细胞明显减少：髓系和红系均明显减少，未见巨
: 核细胞，浆细胞散在增生，请结合临床除外再生障碍性贫血（AA）。
: 免疫组化结果
: CD138(+), CD20(个别+), CD235a(+), CD3(散在+)， CDb1(-1), MPO(+)
: 目前北医三院初步认为是再生障碍性贫血（AA）。各位是否有不同的诊断？该病该如何
: 治疗？谢谢！
:
: 5cm。
|
b**h
发帖数: 293 | 20 骨穿和临床结果都支持再障的诊断。
你妈妈的再障可能比较好治：把胸腺的右页也切掉。 她的再障最有可能是胸腺瘤导致
，胸腺全切多数情况下可根治再障。
【在 v**5 的大作中提到】
: 骨髓穿刺活检病理报告（Nov 20 2012）
: 骨髓穿刺组织腔内以脂肪髓为主，造血细胞明显减少：髓系和红系均明显减少，未见巨
: 核细胞，浆细胞散在增生，请结合临床除外再生障碍性贫血（AA）。
: 免疫组化结果
: CD138(+), CD20(个别+), CD235a(+), CD3(散在+)， CDb1(-1), MPO(+)
: 目前北医三院初步认为是再生障碍性贫血（AA）。各位是否有不同的诊断？该病该如何
: 治疗？谢谢！
:
: 5cm。
|
|
|
v**5
发帖数: 745 | 21 我打算从美国带些营养品回去，请问你有没有什么建议？谢谢！
,
megakaryocytic
【在 l*h 的大作中提到】
: the main differential would be hypocellular MDS.
: it could be quite difficult to distinguish these two in some patients.
: basically, in AA, blood stem cells are decreased in number but their
: functions are normal; in MDS, the number can be either normal or decreased,
: but their functions are abnormal. as a result, in AA, the morphology of
: peripheral blood cells is normal; in MDS, some cells have abnormal
: morphology and may be destroyed prematurely.
: AA usually occurs in children and young adults; MDS usually occurs in the
: elderly. in AA, usually the erythrocytic (red blood cells) lineage is the
: most severely suppressed; in MDS, it could be myeloplastic or megakaryocytic
|
l*h
发帖数: 4124 | 22 my suggestion is balanced nutritional diet. you may want to talk to a
medical nutritionist for more detailed advice.
【在 v**5 的大作中提到】
: 我打算从美国带些营养品回去，请问你有没有什么建议？谢谢！
:
: ,
: megakaryocytic
|
v**5
发帖数: 745 | 23 病人现在已被基本确认为是AA，医生准备开始用环孢素A进行治疗，我们比较担心其对
肝肾的副作用，
不知道在治疗方案和降低激素的毒副作用方面，有什么建议吗？
谢谢！
,
megakaryocytic
【在 l*h 的大作中提到】
: the main differential would be hypocellular MDS.
: it could be quite difficult to distinguish these two in some patients.
: basically, in AA, blood stem cells are decreased in number but their
: functions are normal; in MDS, the number can be either normal or decreased,
: but their functions are abnormal. as a result, in AA, the morphology of
: peripheral blood cells is normal; in MDS, some cells have abnormal
: morphology and may be destroyed prematurely.
: AA usually occurs in children and young adults; MDS usually occurs in the
: elderly. in AA, usually the erythrocytic (red blood cells) lineage is the
: most severely suppressed; in MDS, it could be myeloplastic or megakaryocytic
|
l*h
发帖数: 4124 | 24 If this is a direct copy of the path report, I honestly don't believe proper
differentiation had been performed by either the hematologist or the
pathologist.
this description would fit AA, but would also fit other bone marrow failure
disorders. it seems immunotyping was misused and abused. while they were
reported as positive (I guess your CDb1 should be CD61), which only means
each of those lineages were present (plasma, immature B, erythrocyte, T,
neutrophil and throbocyte), the reporting pathologist didn't bother to
report any major differentiating characteristics (such as morphology of each
type of these cells, and the relative ratio of these cells). It was most
probable the idea of differential diagnosis just didn't pass his mind.
I am not saying the diagnosis of AA is wrong. But I don't have confidence to
believe it's a solid diagnosis.
【在 v**5 的大作中提到】
: 骨髓穿刺活检病理报告（Nov 20 2012）
: 骨髓穿刺组织腔内以脂肪髓为主，造血细胞明显减少：髓系和红系均明显减少，未见巨
: 核细胞，浆细胞散在增生，请结合临床除外再生障碍性贫血（AA）。
: 免疫组化结果
: CD138(+), CD20(个别+), CD235a(+), CD3(散在+)， CDb1(-1), MPO(+)
: 目前北医三院初步认为是再生障碍性贫血（AA）。各位是否有不同的诊断？该病该如何
: 治疗？谢谢！
:
: 5cm。
|
l*h
发帖数: 4124 | 25 tough question.
my standard answer is "close observation."
【在 v**5 的大作中提到】
: 病人现在已被基本确认为是AA，医生准备开始用环孢素A进行治疗，我们比较担心其对
: 肝肾的副作用，
: 不知道在治疗方案和降低激素的毒副作用方面，有什么建议吗？
: 谢谢！
:
: ,
: megakaryocytic
|
l*h
发帖数: 4124 | 26 please clarify "CDb1(-1)"
your "CDb1" seems to be CD61, but what is "(-1)".
【在 v**5 的大作中提到】
: 骨髓穿刺活检病理报告（Nov 20 2012）
: 骨髓穿刺组织腔内以脂肪髓为主，造血细胞明显减少：髓系和红系均明显减少，未见巨
: 核细胞，浆细胞散在增生，请结合临床除外再生障碍性贫血（AA）。
: 免疫组化结果
: CD138(+), CD20(个别+), CD235a(+), CD3(散在+)， CDb1(-1), MPO(+)
: 目前北医三院初步认为是再生障碍性贫血（AA）。各位是否有不同的诊断？该病该如何
: 治疗？谢谢！
:
: 5cm。
|
v**5
发帖数: 745 | 27 是CD61(-)，不好意思当初敲错了。
更新骨髓细胞形态检查报告。
第一幅是11月15日的，第二幅是11月20日的，13日输过血小板，16日输过全血。
点击图片可见大图。谢谢！
proper
failure
each
【在 l*h 的大作中提到】
: If this is a direct copy of the path report, I honestly don't believe proper
: differentiation had been performed by either the hematologist or the
: pathologist.
: this description would fit AA, but would also fit other bone marrow failure
: disorders. it seems immunotyping was misused and abused. while they were
: reported as positive (I guess your CDb1 should be CD61), which only means
: each of those lineages were present (plasma, immature B, erythrocyte, T,
: neutrophil and throbocyte), the reporting pathologist didn't bother to
: report any major differentiating characteristics (such as morphology of each
: type of these cells, and the relative ratio of these cells). It was most
|
v**5
发帖数: 745 | 28 还有一个11月20日做的流式细胞术检测，白血病/淋巴瘤免疫分型报告单。
proper
failure
each
【在 l*h 的大作中提到】
: If this is a direct copy of the path report, I honestly don't believe proper
: differentiation had been performed by either the hematologist or the
: pathologist.
: this description would fit AA, but would also fit other bone marrow failure
: disorders. it seems immunotyping was misused and abused. while they were
: reported as positive (I guess your CDb1 should be CD61), which only means
: each of those lineages were present (plasma, immature B, erythrocyte, T,
: neutrophil and throbocyte), the reporting pathologist didn't bother to
: report any major differentiating characteristics (such as morphology of each
: type of these cells, and the relative ratio of these cells). It was most
|
l*h
发帖数: 4124 | 29 so on that report, there was no megakaryocytes/thrombocytes.
your newly posted results strengthened my discomfort with the diagnosis of
aplastic anemia. if you look at the myelo and erythro lineages, the general
trend is that the further along the maturing process, the further the values
drop below the lower limits. this indicates defects in stem cells resulting
in blood cells with decreased survival (rate and/or length) instead of just
depletion of stem cells.
【在 v**5 的大作中提到】
: 是CD61(-)，不好意思当初敲错了。
: 更新骨髓细胞形态检查报告。
: 第一幅是11月15日的，第二幅是11月20日的，13日输过血小板，16日输过全血。
: 点击图片可见大图。谢谢！
:
: proper
: failure
: each
|
l*h
发帖数: 4124 | 30 i don't like the shapes and size variance of the mature erythrocytes either
if to let this be an AA.
【在 v**5 的大作中提到】
: 是CD61(-)，不好意思当初敲错了。
: 更新骨髓细胞形态检查报告。
: 第一幅是11月15日的，第二幅是11月20日的，13日输过血小板，16日输过全血。
: 点击图片可见大图。谢谢！
:
: proper
: failure
: each
|
|
|
v**5
发帖数: 745 | 31 我可以理解为你的意见还是倾向于MDS吗？
either
【在 l*h 的大作中提到】
: i don't like the shapes and size variance of the mature erythrocytes either
: if to let this be an AA.
|
l*h
发帖数: 4124 | 32 obviously i neither have seen the patient nor have all the information, so
it is difficult for me to give a firm medical opinion. but some of the
results you have shown argue against AA.
some aspects of the treatments for AA and MDS (and related diseases) are
similar, some are different, so there should be enough motive to do a proper
differential diagnosis.
the 11/20 marrow biopsy report implicated AA, but the reporting physician
failed to describe any differential features. the reporting physician on
the bone marrow aspiration reports noted differential features and didn't
put down a conclusion.
i think what you should do now is to get all the docs currently involved (
hematologist clinically taking care of her, hematologist who read the blood
smear and marrow aspiration, pathologist who read her biopsy slides) to have
a serious discussion. ask them to read into aplastic anemia,
myelodysplastic syndrome, myeloproliferative disorders, myelodysplastic-
myeloproliferative hybrid disorders before the meeting. ask them to review
the test results carefully on the meeting.
if she has more recent tests done, including peripheral blood count and
smears, post the results.
for blood/platelet transfusion, care should be taken to prevent the
production of antibodies against platelets. ask her docs whether this was
done.
【在 v**5 的大作中提到】
: 我可以理解为你的意见还是倾向于MDS吗？
:
: either
|
v**5
发帖数: 745 | 33 要求北医和协和的医院会诊恐怕不大可能，只能尽量和协和的医生商量，国内的情况可
能大家都了解。
目前协和认为是重型再生障碍性贫血。
非常感谢你一直以来的专业意见，我明天就回北京了，如果能够翻墙的话会把一些检查
结果贴上来。
proper
【在 l*h 的大作中提到】
: obviously i neither have seen the patient nor have all the information, so
: it is difficult for me to give a firm medical opinion. but some of the
: results you have shown argue against AA.
: some aspects of the treatments for AA and MDS (and related diseases) are
: similar, some are different, so there should be enough motive to do a proper
: differential diagnosis.
: the 11/20 marrow biopsy report implicated AA, but the reporting physician
: failed to describe any differential features. the reporting physician on
: the bone marrow aspiration reports noted differential features and didn't
: put down a conclusion.
|
l*h
发帖数: 4124 | 34 all the best to your family.
the doc who wrote the marrow aspirate reports seem to have some serious
thoughts on the diagnosis. s/he might be the first person you want to
discuss with.
【在 v**5 的大作中提到】
: 要求北医和协和的医院会诊恐怕不大可能，只能尽量和协和的医生商量，国内的情况可
: 能大家都了解。
: 目前协和认为是重型再生障碍性贫血。
: 非常感谢你一直以来的专业意见，我明天就回北京了，如果能够翻墙的话会把一些检查
: 结果贴上来。
:
: proper
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