Fever in children with acute lymphoblastic leukemia

Early Discharge of Adolescent and Young Adult Patients During Induction Chemotherapy for Newly Diagnosed Acute Lymphoblastic Leukemia: Is It Safe?

There is a lack of consensus for safely discharging adolescent and young adults (AYA) with newly diagnosed acute lymphoblastic leukemia. From 2017 to 2019 we evaluated predefined early discharge criteria for 41 AYA patients during induction chemotherapy. Only 17% (7/41) of patients met criteria for early discharge. Two (29%) patients who were discharged early were readmitted, but not to the pediatric intensive care unit (PICU). This outcome was compared to a historic cohort at our institution of 73 patients who were discharged without predefined discharge criteria. Twenty-seven (37%, p = 0.7) patients were readmitted, but 13 (48%) were readmitted to the PICU (p = 0.004).

Factors associated with a prolonged hospital stay during induction chemotherapy in newly diagnosed high risk pediatric acute lymphoblastic leukemia

BACKGROUND

High Risk (HR) or Very High Risk (VHR) acute lymphoblastic leukemia (ALL) treated with 4 drug induction chemotherapy is often associated with adverse events. The aim of this study was to identify risk factors associated with a prolonged inpatient length of stay LOS during induction chemotherapy.

PROCEDURE

Data from patients (N = 73) (age<21 years) was collected through a retrospective chart review. Univariable and multivariable logistic regression was used to test for statistical significance. The overall survival and disease (leukemia)-free survival were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

Of the 73 patients, 42 (57%) patients were discharged on day 4 of induction (short LOS, group A), while 31 (43%) patients (group B) experienced a prolonged LOS or an ICU stay (16 ± 27.7 days, median hospital stay = 8 days vs 4 days (group A), p = 0.02) due to organ dysfunction, infectious or metabolic complications. Group B patients were more likely to have a lower platelet count, serum bicarbonate, and a higher blood urea nitrogen (BUN) on day 4 of treatment (OR = 4.52, 8.21, and 3.02, respectively, p < 0.05). Multivariable analysis identified low serum bicarbonate (p = 0.002) and a platelet count<20,000/μL (p = 0.02) on day 4 of induction to be predictive of a prolonged LOS. Twenty six (group A (n = 16, 36%) and B (n = 11, 35%), p = 0.8) patients experienced unplanned admissions, within 30 days of discharge.

CONCLUSIONS

A significant proportion of newly diagnosed HR or VHR pediatric ALL patients experience a prolonged LOS and unplanned re-admissions. Aggressive discharge planning and close follow up is indicated in this cohort of patients.

Fever at Diagnosis of Pediatric Acute Lymphoblastic Leukemia: Are Antibiotics Really Necessary?

INTRODUCTION

With new multidrug-resistant microbes and the paucity of new antibacterial agents, we must identify opportunities to safely minimize antibiotics. Current guidelines encourage empiric antibiotics in febrile patients with chemotherapy-induced neutropenia to reduce infection-related mortalities. No guidelines exist for children with isolated fever at presentation/diagnosis of acute lymphoblastic leukemia (ALL) and before starting chemotherapy. This study evaluates the incidence of bacteremia in this subpopulation.

MATERIALS AND METHODS

We retrospectively analyzed medical records of 230 consecutive patients under 21 years of age diagnosed with ALL at Children's Hospital & Research Center Oakland (CHRCO) from January 2003 through October 2013. We focused on blood cultures obtained within 24 hours of presentation to CHRCO, which was before general anesthesia for a procedure or systemic chemotherapy.

RESULTS

Among 221 patients who met the inclusion criteria, 126 (57%) were febrile and had blood cultures obtained. Two patients (1.6%) had positive blood cultures consistent with bacteremia; 1 had group A β-hemolytic streptococcus and the other had Escherichia coli.

DISCUSSION

Given the rarity of bacteremia in this subpopulation at our institution, we recommend more judicious use of antibiotics in children with isolated fever at time of ALL diagnosis. We encourage other institutions to conduct similar investigations.

Primary Cytomegalovirus-Related Eosinophilic Pneumonia in a Three-year-old Child with Acute Lymphoblastic Leukaemia: Case report and literature review

A diagnosis of eosinophilic pneumonia (EP) is rare in patients with acute lymphoblastic leukaemia (ALL). We report a case of EP in association with a primary cytomegalovirus (CMV) infection in a three-year-old Omani child with ALL. The patient presented with fever while undergoing maintenance chemotherapy. He was admitted to the Child Health Department of Royal Hospital, in Muscat, Oman, in November 2011. He was initially thought to have sepsis but failed to respond to antibiotics. Chest computed tomography showed diffuse ground glass lung opacification. Bronchoalveolar lavage (BAL) cytology was consistent with the diagnosis of EP. Polymerase chain reaction tests for CMV were performed on the BAL and blood samples and were both markedly elevated. The patient made a full recovery after treatment with prednisolone and ganciclovir. The association between CMV infection and EP as well as the management of this combination in immunocompromised patients has never been reported in the English literature.

Risk factors for readmission after initial diagnosis in children with acute lymphoblastic leukemia

BACKGROUND

Specific hospital discharge criteria following the initial diagnosis of children with acute lymphoblastic leukemia (ALL) have not been reported. This retrospective cohort study was designed to identify risk factors for readmission during induction therapy, to assist with development of discharge guidelines.

PROCEDURE

We reviewed the records of 142 consecutive children with newly diagnosed B-precursor ALL and found 129 eligible patients. Chi square, t-test, and multivariate logistic regression analysis were used to compare differences in absolute neutrophil count (ANC), NCI risk status, age, type of corticosteroid administered, and other potential risk factors for readmission during induction therapy.

RESULTS

ANC at initial hospital discharge was the only significant predictor of readmission for fever during induction therapy (P = 0.006) by multivariate analysis. Specifically an ANC <or=200/mm(3) at discharge had the strongest association with readmission for fever (OR 3.3, 95% CI 1.422, 7.729).

CONCLUSION

An ANC >200/mm(3), in a clinically stable patient, is associated with minimal risk of readmission during induction therapy following the initial diagnosis of ALL.

Acute lymphoblastic leukemia. A comprehensive review with emphasis on biology and therapy

BACKGROUND

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children. It is now curable in 60-70% of children. Most of the current understanding of the biology and treatment of ALL originates from studies of children. In adults, although much progress has been achieved, ALL is curable in only 20-35% of patients.

METHODS

A review of the biology and treatment of ALL from the English literature was performed.

RESULTS

Immunophenotypic and cytogenetic analyses of ALL have contributed to a more rational classification of ALL. These analyses have identified subgroups with poor prognosis or with different therapeutic requirements. Overall, 60-70% of adults with ALL have poor prognostic features, including older age, a high leukocyte count, non-T-cell immunophenotype, Ph-positive genotype, and longer time to achieve a complete remission. These patients have a cure rate of 20-25%, whereas those without these risk factors, have a 60-70% probability of survival. The use of more intensive induction regimens with growth factor support may improve survival rates. Also, intensive consolidation-intensification may improve survival rates. Most patients benefit from maintenance therapy, but the dose schedule must be optimized. Central nervous system (CNS) prophylaxis is beneficial, particularly for patients with a high risk for CNS relapse and when introduced early during induction of remission. Patients with high risk characteristics may benefit from allogeneic bone marrow transplantation (BMT) during first remission, and all other patients may benefit from it during first or subsequent relapse. Autologous BMT may be a valuable option for poor compliant patients.

CONCLUSIONS

Although the prognosis of patients with ALL has improved markedly during the past decades, newer strategies, including more dose-intensive therapy, the search for new drugs, and more target-specific therapy, are needed to improve the current cure rates.

The yield of routine chest radiography in children with cancer hospitalized for fever and neutropenia

A routine admission chest radiograph (CXR) in pediatric patients with cancer who are admitted to the hospital for fever and neutropenia has been advised because the signs and symptoms of pneumonia may be absent. The authors studied 131 consecutive patient admissions for fever and neutropenia to evaluate the diagnostic yield of routine CXR. All patients had a complete history, physical examination, complete blood count, blood culture, urinalysis, urine culture, and CXR. Patients routinely started ceftazidime monotherapy. Results of the CXR were correlated with the presence or absence of signs and symptoms of respiratory disease. Of 128 CXR results, 26 (20%) were abnormal (13 with known malignant disease, 2 with atelectasis, 3 with peribronchial cuffing, and 8 with pneumonia [6%]). Three patients with pneumonia were asymptomatic. Therefore, only 3 of 128 patients (2.3%) had pneumonia on CXR not suspected by physical examination. None would have had initial therapy modified based on the CXR finding alone. The authors concluded that the incidence of pneumonia in a child with fever and neutropenia is low and that routine CXR at diagnostic evaluation is unnecessary in the asymptomatic ambulatory patient.

Treatment of childhood acute lymphoblastic leukemia in Malaysia, 1976-1982

One hundred four children with acute lymphoblastic leukaemia were diagnosed at the University Hospital, Kuala Lumpur, Malaysia, between 1976 and 1982; 87 were evaluable with respect to treatment. They were divided into good prognosis (GP) and bad prognosis (BP) groups based on their initial total white cell count, their treatment differing only during the maintenance phase. Remission was achieved in 82 patients (94%) of whom ten (12%) subsequently died in remission from infection. Twenty-eight (34%) relapsed while on treatment and three while off therapy. Eleven patients ceased treatment after 3 yr of continuous complete remission (CCR). Three of these later relapsed, two within the first year. Survival in CCR was significantly better in the GP group up to 30 months, after which the difference diminished. There was no difference in survival between boys and girls. The overall disease-free survival at 3 yr and 5 yr was 40% and 25%, respectively, with a median follow-up period of 20 months (range 4-69 months). The reasons for the relatively low survival rates as compared with those in developed countries are discussed.

Fever in acute myelogenous leukemia

Twenty patients with acute myelocytic leukemia were observed over a period of 16.5 patient years in an attempt to identify any relationship between fever, granulocytopenia (<1000 gran ulocytes/μl), infection, and disease status. An infectious origin for fever in association with gran ulocytopenia could be established in the majority of instances during the induction of remission and during relapse. This finding differs from what has been previously noted in children with the more common form of leukemia, acute lymphocytic leukemia.