(Stamp)
The Ministry of Health of Ukraine
Lugansk Oblast Children Clinic Hospital
Polyclinic Department
EXTRACT
from case record # 16
The girl Lan Natalya Yevgenyevna, DOB 05.06.92; address Lugansk Oblast, Svatovo, Voli str., 79, has been registered with hematologist with the following diagnosis:
Myeloplastic syndrome – refractory cytopenia.
This diagnosis was stated clinically, morphologically, and it was confirmed by histological results of huckle-bones trepanobiopsy dated 14.07.2003 (in the Department of Children Oncohematology of NVH in Donetsk) – the bone preparation revealed complete absence of bone marrow activity, its substitution by bone tissue, hemorrhage, and only small zones of cells, among which there were pro-lymphocytes, lymphocytes, and reticular cells. Trepanobiobsy of huckle bones: the bone preparation revealed complete absence of bone marrow activity, its substitution by fat tissue, only small zones of cells, among which there were single pro-lymphocytes, lymphocytes, and reticular cells. Myelogram dated 15.07.03: promyelocytes – 1.5%; myelocytes – 17.5%; e – 0.5%; young/immature – 7%; stab neutrophils – 6%; immature segmental leucocytes – 11.5%; e – 0.5%; l – 12%; plasmatic cells – 9%; erythroblasts – 1%; immature blasts – 6.5%; p – 28%; o – 2%; c/m of decreased cellularity. Index l/e 1.5:1; index of neutrophils maturation – 1.3; index of maturation – 0.7; megakaryocytic stem function was decreased. Patient blood group O(I), Rh positive.
After the diagnosis statement the girl started from 28.07.08 in Department of Hematology of LODKB (Lugansk Oblast Children Clinical Hospital) the therapy with sandimmun 200 mg/day, with eprex, and with polyvitamins. In January 2004 due to prolonged uteral bleeding there was anemia exacerbation with hemoglobin fall up to 50 g/l (we carried out substitutive hemotransfusion with red blood cells mass of O(I), Rh (+) and Primolut-nor (Norethisterone) therapy). During 2004 the girl twice stayed for examination and treatment in Department of Oncohematology of Ukrainian Children Clinical Hospital OHMATDET (on 15.06.04 we carried out biopsy of huckle-bone fragment and detected narrowing of bone marrow space). From 01.04 until 05.04 the girl stayed for treatment in Hematological Department of LODKB due to menorrhagii – she received treatment of herpes and CMV infections (visceral form): hepatitis of medium severity.
On 09. – 27.06.04 the patient was examined in Oncohematology Center of OHMATDET Clinic in Kiev: myelogram dated 10.06.04 showed that bone marrow was rich with cell elements. There was inhibition of megakaryocytic stem. Erithron was irritated with signs of lyserithrocytosis. Granulocytic stem demonstrated immature forms domination. On 10.06.04 we did not reveal markers of viruses of hepatitis B,C, Herpes virus of type I and II E-BV, CMV by PCR method. On 15.06.04 – huckle-bone biopsy revealed disturbed bone marrow architecture, narrowing of bone marrow space, fibrous fibrosis nidi. The bone marrow picture showed proliferation of leucocytic cells, to the less extent of erythrocytic. We also discovered zones of hypo cellular bone marrow. We could not detect thrombocytic cells.
The girl took cyclosporine A for a long time as monotherapy, and we did not register its considerable effect. In April 2006 the preparation was cancelled due to nephrotoxicity. During the following year the patient clinical and hematological condition was stable. In the beginning of November 2007 the hemoglobin level decreased. In OHMATDET Clinic doctors repeatedly examined huckle-bone preparation and confirmed the diagnosis. The girl received course of antithymocytic globuline ATGAM (from 06.11 to 27 12.07), and of G-CSF (grasalv) 5 mg/kg/day (from 07.12 to 27.12.07). After the attempt of renewing cyclosporine A in the dose 3 mg/kg we again noted nephrotoxicity signs (level of azotaemia increased), which caused modifications of immunosuppressive therapy: from 11.12.07 the girl received selsept in the dose 20 mg/kg for three months – without any effect.
On 01.08 the girl was examined in OHMATDET Clinic: myelogram showed that by 42 day of ATGAM therapy there was partial remission (partial suppression of megacariocytic stem). We carried out HLA-typing of the girl family in order to decide about possible allogenic bone marrow transplantation – there was no identical family donor of bone marrow. On 07.08 we carried out bone marrow puncture: along with moderate cellularity decrease there was relative erythron decrease, and deep hypoplasia of megakaryocytic stem; we revealed hypo globular myelocariocytic microforms; we did not reveal pronounced signs of dysmyelopoiesis and dyserythropoiesis.
The last hospitalization into Department of Oncohematology of LODKB was on 20.08.08. Clinical blood test dated 20.08.08: Hb – 53 g/l, er – 1.5x1012/l, ret – 0.7%, tr – 24x109/l, L – 4.0x109/l, e – 2%, stab – 2%. S – 68%, l – 23%, m – 6%, ESR – 40 mm/h, ci – 1.0.
On 21.08.08 we carried out substitute transfusion with erythrocytic mass, group O(I), Rh (+).
29.08.08. - Hb – 87 g/l, er – 2.8x1012/l, tr – 24x109/l, L – 5.0x109/l, e – 2%, stab – 3%. S – 74%, l – 20%, m – 3%, ESR – 12 mm/h.
This extract was complied at the instance of the girl's mother.
17.09.08
Director of Department of Oncohematology (Signature) Rudenko T.G.
(Stamp)
Lugansk Oblast Children Clinical Hospital
Department of Oncohematology
CONCLUSION #... dated …
About the necessity of sending the patient for treatment abroad
The girl Lan Natalya Yevgenyevna
Year of birth 1992
Address: vil. Svatovo, Lugansk region.
Diagnosis: myelodysplastic syndrome (aplastic anemia)
Cause of necessity to send the patient abroad for treatment: bone marrow transplantation from non-related donor (impossible in Ukraine).
Recommended countries, and medical centers abroad: Bielorussian Center of Children Oncology and Hematology, Mogyliv city.
Approximate treatment cost: 155,000 USD.
Source of financing: the Ministry of Health of Ukraine.
Chief Specialist of the Ministry of Health of Ukraine
on Children Hematology (Signature) S. Donskaya
THE REPUBLIC OF BELARUS
THE REPUBLICAN SCIENTIFIC-PRACTICAL CENTER OF CHILDREN ONCOLOGY AND HEMATOLOGY
(RNPZDOG)
223053, Minskiy region, Lesnoye
Tel./fax (017) 268-82-22
Date: 23.10.2008, # 1-35/1176
State Enterprise “The Republican Scientific-Practical Center of Children Oncology and Hematology” certifies that the citizen of Ukraine Lan Natalya, born in 1992, with diagnosis – acquired aplastic anemia, stayed in the Center for medical examinations from October 17, 2008.
The further treatment demands bone marrow transplantation from unrelated donor. For the transplantation and the further treatment the patient needs the total of 155,000.0 (one hundred fifty five thousand) USD, which includes buying and transportation of hemopoietic stem cells from Germany – 15,000.0 (fifteen thousand) USD.
This treatment cost is not definitive, and it may change depending on treatment type.
Director (Signature) O. Aleynikova
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