Age: 45.0
Sex: F
Vaccine: COVID19, FLU4, HEPA, TDAP
Symptoms: Transfusion-related circulatory overload, White blood cell count increased, X-ray normal
Clinical narrative: Primary Care Physician at Discharge: DO  Hematologist/Oncologist: Dr.   Admission Date: 2/10/2023 Discharge Date: 03/11/2023 Patient's Discharge Disposition:  Home in stable condition. This is a a 46 yo female with a history of ADHD who presented to the ED on 2/10/23 with findings of elevated WBC and concerns for acute leukemia. Peripheral smear on 2/10 was consistent with acute leukemia. On presentation she had anterior cervical lymphadenopathy and concerns for sinusitis and tonsillitis. CT neck 2/10 showed several mildly enlarged level 1 and 2 lymph nodes as well as mildly prominent retropharyngeal lymph nodes findings concerning for possible tonsillitis/sinusitis. The patient was found to be positive for Covid-19 on admisison. She was treated with dex 2/10-2/15 and Remdesivir and remained stable. Bone marrow biopsy done 2/13 (in IR) was positive for AML, normal kayotype, FLT3-TKD mutated and NPM! Mutated. Panorex with no acute findings. ECHO with LVEF 64%. Hepatitis and HIV were negative. HLA typing was sent. PICC line was placed 2/15. She started induction chemo on 2/15/23 with 7+3 and then started Rydapt/Midostaurin D8-21. Day 21 IR bone marrow done 3/7 showed approximately 80% cellular bone marrow, no evidence of leukemia. She did have recurrent sinus pain and neck swelling. CT sinus/neck on 3/5 showed pansinusitis, possible otomastoiditis.  ENT did see her and did not have concern for acute mastoididits. Blood cultures were negative. ID was consulted. She was on broad spectrum antibiotics. . During her nadir she also had neutropenic fevers and recurrent acute hypoxemic respiratory failure. CT thorax 3/5 showed diffuse bilateral interstitial ground glass opacities. ECHO 3/5/23 showed an EF of 55%, previously was 64%. Pulmonary was consulted and felt respiratory failure related to fluid overload vs TRALI/TACO with frequent transfusions. She was started on IV lasix BID and had good results and improvement with diuresis. She developed a rash thought to be related to cefepime and ultimately improved once antibiotics were changed. She was treated with with merrem, vancomycin, micafungin, and nystatin through 3/10 when her counts recovered. ID recommended observing off antibiotics. At discharge they recommended ppx acyclovir but with negative bone marrow biopsy from Day 21 antifungal medications. She was also on IV steroids which will be quickly tapered down at discharge. She has been weaned off O2 inpatient. The patient's counts recovered with no evidence of leukemia on D21 Bone marrow biopsy the patient is stable for discharge home today. PICC line was removed. She lives in the area and would like to get labs on Tuesdays/Thursdays in the office but will follow-up with Dr. at clinic. Per weekend attending she will need another IR bone marrow biopsy next week now that her counts have recovered. We will arrange outpatient IR bone marrow biopsy and f/u with Dr. after that is done. She is discharging home in stable condition.    Incidental findings this admission:  -CT sinuses 3/5 showed prominence of the sella- probably related to empty sella-- patient was asymptomatic with these findings.  -CT AP 2/10 showed splenomegaly, multiple vascular lesions throughout liver-likely hemangiomas and MRI abdomen 2/14 showed focal nodular hyperplasia in the right lobe of liver. Has had Mild LFT elevation, but stable.  -CT AP 2/14 showed complex partially exophytic cyst at the upper pole of right kidney, ? Bosniak III cyst. Urology plans f/u in 4 months to discuss further treatment plan.  -MRI 2/14 right adrenal adenoma- urology evaluated-- 24h urine cortisol (<3.4), plasma fractionated metanephrines (<0.20), DHEA sulfate (low at 12.4) and aldosterone (10.7) level