Group Health Cooperative of Puget Sound
Tacoma Specialty Center
2029 So. "K" Street
Tacoma, WA 98405

June 11, 1993

Commander, Code 1113.122
Puget Sound Naval Shipyard
Bremerton, Washington 98314-5000

RE: Robert F. Farmer

Dear Sir:

Mr. Farmer is a 50-year-old white male who was first seen by me in Hematology Clinic on February 22, 1993, when he presented with a white count of 130,000, increasing to 154,000 shortly after his initial CBC. At that time he had a normal platelet count and normal hematocrit. Differential showed left shift with increased basophils, myelocytes, promyelocytes, and blasts, as well as occasional nucleated red cells. Bone marrow aspiration & biopsy on February 22 confirmed myeloid hyperplasia consistent with chronic myelocytic leukemia and cytogenetics done confirmed the presence of a Philadelphia chromosome with no other chromosomal abnormalities. The patient was begun on Hydroxyurea and has been maintained on that drug to try to control his white count with variable efficiency since. The patient had noted symptoms of fatigue starting around Christmas time in 1992, with some variable aching in the legs and hips, also pruritus without rash. He also complained of having symptoms of feeling flushed and warm, although he had not had a documented fever. He began to note increasing fatigue which is what led to the initial CBC. The patient is scheduled for bone marrow transplant in August 1993 from his HLA compatible sibling.

The patient's past medical history is significant for a long history of frequent headaches, sinus type symptoms, which have been recurrent and just prior to his diagnosis of CML he had episodes of blurring of vision without diplopia, but he had no other neurological symptoms such as numbness, tingling, loss of balance or coordination. He had complained of difficulty concentrating for some years and felt depressed. He has had some mild hearing loss in the past. The patient had no definite asthmatic type symptoms. Other symptoms he noted at the time of CML diagnosis were epigastric distress which he described as indigestion without reflux type symptomatology and frequent stooling over the last several weeks prior to diagnosis without significant distention, crampy abdominal pain, nausea or vomiting. Since his diagnosis he has had continued problems with arthralgias and myalgias without clear arthritis. He has had no rash. His episodes of fatigue are intermittent, some days he feels quite well and other days he feels very tired. He has had some conjunctivitis requiring antibiotic treatment with Keflex and gentamycin eyedrops into his left eye. This has responded fairly slowly. He has had no other definite infections. The white count has been difficult to keep on an even keel, with values dropping to the 6500 range and then going back up to 50,000, as the Hydrea dose is regulated. His symptoms do not appear to correspond to the control of his CML, however. He has not shown any evidence of increasing blasts or basophils consisting with impending blast transformation, but his disease has been somewhat difficult to consistently control well.

The plan is to continue to try to regulate his white count with Hydroxyurea, but it may require a trial of busulfan. The bone marrow transplant is expected to have a substantial chance of cure, however toxicities of bone marrow transplant can be significant, including fatality from infection and varying degrees of graft versus host disease, ranging from fatal to none. The average graft versus host disease severity is mild to moderate in this age group and he has a chance of long term disease-free survival, probably at least 60 percent, hopefully without long term symptomatology from GVH disease. I suspect that it will take the patient some 6 months or so post-transplant to return to normal function. Immune recovery may take somewhat longer-up to one year, but usually individuals are capable of functioning at work after 6 months or so, assuming the patient does not have graft versus host disease. The appearance of that entity in significant degree can lead to chronic debilitation, including chronic diarrhea and malabsorption syndrome, skin rash, renal disease and hypertension and thickening of the skin. Post-transplant the patient will be followed in Hematology Clinic and symptoms managed there.

Sincerely,

Irwin Dabe, M.D.

Oncology Clinic
Tacoma Specialty Center
Group Health Cooperative

ID/lmr