Chronic myeloid leukaemia (CML) is characterised by a massive over-production of white blood cells. The abnormal cells develop from early blood cells called the myeloid blood stem cells. They become myelocytes and are sometimes called granulocytes.

Patient profile

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Adnan Baqir is in his mid-40s and married with two children. He works night shifts at a local paint factory. This is his third visit to his GP, Dr Bollands, presenting with fatigue.

Consultation 1

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Summary of symptoms

• Persistent fatigue that is now affecting Adnan’s normal routine as he doesn’t attend his son’s football matches
• Changes in mood – more irritable than usual
• Pain in upper left quadrant, worsening

Reflection

Dr Sarah Taylor talks to Dr Steve Tomkinson and Dr Richard Roope about assessing the impact of fatigue and patients who visit their GP multiple times with the same symptom set.

[Combine videos – remove consultation sections at start]

Key Points:

• Use short, open questions
• Keep the patient talking so that they share their experience in their own words
• Asking ‘how is the tiredness affecting you?’ can illuminate the impact of the tiredness
• If the patient presents three times with the same symptom, think cancer
• NICE NG12 guidelines state that you should consider a very urgent blood count if a patient presents repeatedly with persistent fatigue

Symptoms of CML

Adnan presented with fatigue and a pain in his upper left quadrant. However, many patients with CML have few or no symptoms at the time they are diagnosed. Their CML is discovered following a blood test as part of a routine check-up or for another condition. However, if the disease has progressed symptoms become more likely.
Dr Adrian Bloor talks to Dr Sarah Taylor about symptoms of CML.

Due to blood abnormalities, low-grade leukaemias can present with:

• Anaemia and fatigue
• Headaches
• Non-specific symptoms (for example, unintentional weight loss, appetite loss, or simply feeling ‘not right’)
• Bleeding and bruising
• Predisposition to infections

There have been cases of atypical presentation of CML, such as blurred vision. Some studies have shown that 5-10% of CML patients present with eye symptoms at initial diagnosis.

Dr Bollands both examined Adnan and ordered a full blood count after he presented with fatigue and pain in his upper left quadrant.

Why has the GP ordered a full blood count?

A full blood count (FBC) is a good diagnostic test to ascertain if Adnan’s tiredness is pathological or lifestyle related.  An FBC will diagnose several conditions, including chronic leukaemias, anaemia or raised platelets, all of which could be causing Adnan’s symptoms.

Dr Adrian Bloor talks to Dr Sarah Taylor about the importance of a full blood count in making a diagnosis of CML.

Key points:

• Patients with early phases of CML will have a mild abnormality with their blood count, but typically will not be symptomatic
• Symptomatic patients will likely have a very high white blood count, as the disease has progressed, and a big spleen that can be palpated on examination
• Blood results should not require much interpretation by the GP and the laboratory/haematologist will clarify if the diagnosis is CML or CLL

What is the GP examining Adnan for?

An enlarged spleen occurs in approximately one half of all CML patients (Leukaemia Care); the extra blood cells produced are stored in the spleen causing it to become swollen. Dr Bollands has decided to examine Adnan as he had presented with a pain in his upper left quadrant.

• The spleen can be large and at 4cm below costal margin is relatively easy to palpate
• It can be below umbilicus
• A primary care practitioner should be able to locate the spleen unless the patient is obese
• An ultrasound would easily resolve any uncertainty about the size of the spleen
• On examination, the spleen would typically be firm, smooth and non-tender

Adnan’s symptoms could be due to a number of medical and/or lifestyle issues.
Click on the icons below to see the NICE NG12 guidance regarding full blood counts.

Additional resources

Link: Chronic Myeloid Leukaemia (CML), Leukaemia Care (2018)
Link: Chronic Myeloid Leukaemia (CML), Cancer Research UK (2019)
Link: Spleen problems and removal, NHS (2019)
Link: Chronic Myeloid Leukaemia symptoms, Cancer Research UK (2019)
Link: Visual disturbance as the first symptom of chronic myeloid leukaemia, Middle East African Journal of Opthamology (2011)
Link: Atypical presentation of CML with visual disturbance, J NTR Health Sci [serial online] (2018)