Caso clinico ediel

Introducción:

Presentamos un caso de probable anemia aplásica inducida
por carbamazepina en una mujer sin otros signos
aparentes de toxicidad por el fármaco. La evolución de
la anemia aplásica fue determinante para la supervivencia
del paciente.

Caso clínico:

Poza rica de Hgo. Ver. 03 de agosto 2001:

Paciente masculino de 13 años de edad es enviado al hospital infantil de México“Dr. Federico Gómez” por la Dra. Rita Reyes Pérez del centro pediátrico ubicado en la colonia Obrera de esta ciudad; al presentar equimosis, gingivorragia, petequias generalizadas de 1 mes de evolución, se realizan estudios de laboratorio en los cuales se observa falla medular (Hb 6.9, leucocitos 2,800, plaquetas 3000, linfocitos 87%, seg.13% y retis 0.1 %).no contando con los medios necesarios paratransfundir concentrados plaquetarios y por el alto riesgo de sangrar se envía para valoración y tratamiento. Dx.LLA vs A.A.

06 de agosto del 2001:

Ingresa al Instituto Mexicano del Seguro Social de la Cd. De Veracruz , donde se hace protocolo de estudio, por presentar anemia, clínica y por laboratorio, con equimosis en diferentes partes del cuerpo (piernas, brazos y posterior tronco).Este instituto envía a Hemopediatria quien maneja con transfusiones sanguíneas al quedar hospitalizado durante 1 año un mes, en reposo absoluto.

Se le realiza asp. de médula ósea encontrándose solo aplasia medular, por lo que se inicia a suministrar prednisona a 50 mgs. diario. Por no presentar respuesta se agrega al manejo ciclosporina a 8 mgs. / kgs. en una sola toma. No hay respuestafavorable por lo cual se agrega danzol 600 mgs. vo. diario. Se obtiene buena respuesta parcial al haberse distanciado la necesidad de transfusiones continuas, solo ha requerido de transfusiones de paq. globular cada dos o tres semanas, hasta la fecha en que está en espera de trasplante medular.

Diciembre del 2001:

El paciente cuenta con 14 años de edad, portador de aplasia medular entratamiento, cursa con plaquetopenia importante, tratada con concentrados plaquetarios para disminuir la sensibilidad del paciente. Tiene cuatro meses de estancia en el servicio durante los cuales, las cifras de plaquetas han oscilado la cifra máxima alcanzada de 79,000/mm3 , con importante disminución en cifras de control , el último reporte de plaquetas de 5,000/mm3 clínicamente con aparición deplaquetas.

Septiembre del 2002:

El último reporte de BH del mes presenta HB de 8 , leucos 5400 y plaquetas 6370 se transfunde paquete globular y es dado de alta con cita abierta a urgencias en caso de complicaciones traslado inmediato a la CD. de Veracruz.

Noviembre del 2002:

Es egresado del instituto mexicano del seguro social durante 15 días sin complicaciones de ningún tipo, ingresa denuevo al instituto, se hospitaliza para valoración de transfusión, al resultado de BH. con hb. de 9.05, hto 19, plaq. 15000 por apreciación 30000.

Dado a que se le encuentra bien se da de alta con cita abierta a urgencias en caso de requerir hospitalización. Saliendo bajo las siguientes condiciones:

• Reposo absoluto en su domicilio.

• Dieta normal, a base de alimentos naturales.• No ingerir embutidos ni productos enlatados.

• Tratamiento: danazol (100 capsulas) 3 caps. Cada 12 hrs.

Se ordena tomar BHC en Poza Rica, y si la HB es menor de 8 trasfundir un paquete globular.

Marzo del 2003:

El paciente cuenta ya con 15 años de edad. Cuenta con anemia aplasica con altos requerimiento de conc. Eritrocitaria , no ha habido respuesta esperada conestimulantes eritropoyetarios, pero esta compensado y asintomático con palides marcada de tegumentos sin manifestaciones hemorrágicas. Cuenta con una evolución de un año 7 meses.

El último reporte de lab. Del mes de marzo

[pic]

Al tener una ligera mejoría y mantenerse estable se le otorgan citas cada mes.

El trasplante de Médula ósea es descartado al no poder ser compatible, por lo que…

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