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Ni J, Chen M, Su Y, Gao Q, Liu L, Lu X. Right femoral vein and right dorsal artery thrombosis in childhood acute myeloid leukemia: A case report. Medicine (Baltimore) 2023; 102:e35121. [PMID: 37832057 PMCID: PMC10578772 DOI: 10.1097/md.0000000000035121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND It is rare for newly diagnosed (de novo) or newly treated acute myeloid leukemia (AML) complicated with thrombotic complications, especially combined arterial and venous thrombosis. METHODS We reported a 13-year-old boy diagnosed with AML and leukocytosis, who developed right femoral vein and right dorsal artery thrombosis during chemotherapy. After treatment with low molecular weight heparin, diosmin, and alprostadil, symptoms were relieved. Unfortunately, the child suffered from coagulopathy afterward, which was unexpectedly caused by vitamin K deficiency. RESULTS After supplementation with vitamin K and prothrombin complex concentrate, coagulation function recovered. CONCLUSION For childhood AML patients with high thrombotic risks, close monitoring during anticoagulant treatment was necessary. Concomitantly, we should be alert to past medication history and combined medication use, especially those that may lead to vitamin K deficiency, secondary bleeding, and coagulation disorders. Rational use of antibiotics, anticoagulants, and antitumor drugs must be guaranteed.
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Affiliation(s)
- Jiaqi Ni
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Min Chen
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yali Su
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Qianqian Gao
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingjun Liu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Lu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
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Analysis of Risk Factors of Coagulation Dysfunction and Hemorrhage in Newly Diagnosed Hyperleukocytic Acute Myeloma Leukemia. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:7828230. [PMID: 35935316 PMCID: PMC9300275 DOI: 10.1155/2022/7828230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/06/2022] [Accepted: 05/27/2022] [Indexed: 11/22/2022]
Abstract
Purpose To explore whether and why abnormal coagulation function and hemorrhage can appear in patients with hyperleukocytic acute myeloid leukemia (HAML). Method We retrospectively reviewed the charts of 724 acute myeloid leukemia (AML) patients admitted with a white blood cell count of >100 × 109/L between 2010 and 2019 in order to analyze the coagulation index of patients with HAML and explore the correlation of abnormal coagulation. Result Prothrombin time (PT) was extended in group HAML compared with group non-HAML. Respiratory failure, intracranial hemorrhage, and infection were more common in the HAML group. Among the 76 HAML patients, there were 33 patients who had ≥3 abnormal items of coagulation index, and 51.5% of them had level 2 hemorrhage which was more than level 0 hemorrhage, and the difference is statistically significant (P < 0.01). Similarly, we can discover that 40.9% of patients with 2 abnormal items had level 2 hemorrhage in contrast to 0 abnormal items. The use of hydroxyurea had a significant effect on PT and D-dimer (DD). Survival analysis by the Kaplan–Meier method showed that there were statistically significant differences in white blood cell (WBC) count>200 × 109//L and DD. Abnormal PT is associated with WBC count>200 × 109//L, and abnormal activated partial thromboplastin time (APTT) is associated with HLA-DR mutation. Infection and respiratory failure were independent influencing factors for the coagulation of patients. Conclusion DD had a marked effect on the survival rate. Infection and respiratory failure were independent influencing factors for the coagulation of patients.
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Macaron W, Sargsyan Z, Short NJ. Hyperleukocytosis and leukostasis in acute and chronic leukemias. Leuk Lymphoma 2022; 63:1780-1791. [DOI: 10.1080/10428194.2022.2056178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Walid Macaron
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zaven Sargsyan
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Nicholas J. Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Olivieri M, Kurnik K, Heinen F, Schmid I, Hoffmann F, Reiter K, Gerstl L. Epileptic Seizure, Postictal Hemiparesis, and Hyperleukocytosis. Glob Pediatr Health 2017; 3:2333794X16681934. [PMID: 28229095 PMCID: PMC5308527 DOI: 10.1177/2333794x16681934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction: Acute ischemic stroke (AIS) is a rare event in infancy. Besides vasculopathy, thrombophilia, or cardiac disorders, cancer and chemotherapy are known predisposing factors for AIS. Leukemia can be associated with different abnormal coagulation parameters, but severe bleeding or thrombosis occurs rarely. Clinical Course: We report the case of a 2-year-old boy who was presented to our emergency ward after a prolonged seizure with right sided postictal hemiparesis. Cranial computed tomography scan revealed a large infarction and edema due to thrombosis of the left carotid artery, the middle cerebral artery, and the anterior cerebral artery. Laboratory workup showed 196 g/L leukocytes with 75% myeloid blast cells. Immediate exchange transfusion, hydration, and chemotherapy with cytarabine were started. During the hospital course intracranial pressure increased and the patient developed a unilateral dilated pupil unresponsive to light. Cranial computed tomography scan revealed a new infarction in the right middle cerebral artery territory. Refractory increased intracranial pressure and brain stem herniation developed, and the child died 3 days after admission to hospital. Conclusion: Seizures with postictal hemiparesis due to cerebral infarction can be a rare manifestation of acute myeloid leukemia. Leukocytosis and cancer-induced coagulopathy are main reasons for thrombosis and/or hemorrhage. High leukocyte counts need immediate interventions with hydration, careful chemotherapy, and perhaps exchange transfusion or leukapharesis. In the presence of thrombosis, anticoagulation must be discussed despite the risk of bleeding due to hyperfibrinolysis and low platelet counts. Mortality may be reduced by awareness of this rare presentation of leukemia and prompt institution of leucoreductive treatment.
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Affiliation(s)
| | - Karin Kurnik
- Dr. von Hauner Children's Hospital, LMU Munich, Germany
| | | | - Irene Schmid
- Dr. von Hauner Children's Hospital, LMU Munich, Germany
| | | | - Karl Reiter
- Dr. von Hauner Children's Hospital, LMU Munich, Germany
| | - Lucia Gerstl
- Dr. von Hauner Children's Hospital, LMU Munich, Germany
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5
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Canet E, Vincent F, Darmon M, Soares M. Acute kidney injury in hematological patients. Curr Opin Crit Care 2016; 21:549-58. [PMID: 26539929 DOI: 10.1097/mcc.0000000000000253] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The present article reviews the recent literature on the main aspects of acute kidney injury (AKI) developing in patients with hematological malignancies admitted to ICU. RECENT FINDINGS Up to two thirds of critically ill patients with hematological malignancies develop AKI. Current mortality rates range from 40 to 60% for most patients with hematological malignancies, except for recipients of allogeneic hematopoietic stem cell transplantation in whom outcomes remain very poor. Renal function recovery occurs in most patients with AKI, but is dependent on the underlying causes. AKI is usually multifactorial, resulting from causes common to other ICU patients and related to the underlying malignancy or its treatment. New targeted therapies and treatment strategies are potentially associated with AKI. Management of these patients requires a high degree of suspicion, close monitoring of metabolic parameters, and use of preventive strategies to limit risk of AKI or to mitigate its severity. SUMMARY AKI is a frequent and severe complication in critically ill patients with hematological malignancies. As the clinical management is complex, close collaboration with hematologists is paramount.
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Affiliation(s)
- Emmanuel Canet
- aMedical Intensive Care Unit, Saint-Louis University Hospital, Paris bMedical-Surgical Intensive Care Unit, Intercommunal Hospital Le Raincy-Montfermeil, Montfermeil cMedical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, Saint-Priest-En-Jarez and Jean Monnet Medical School, Saint-Etienne, France dDepartment of Critical Care, D'Or Institute for Research and Education ePost-Graduation Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
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6
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7
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Pham HP, Schwartz J. How we approach a patient with symptoms of leukostasis requiring emergent leukocytapheresis. Transfusion 2015; 55:2306-11; quiz 2305. [PMID: 26267387 DOI: 10.1111/trf.13210] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/17/2015] [Accepted: 05/17/2015] [Indexed: 01/26/2023]
Abstract
Hyperleukocytosis can induce leukostasis, which can lead to vascular obstructions (usually in the lungs and central nervous system), tumor lysis syndrome, and disseminated intravascular coagulation. Although it has not been conclusively shown to improve long-term outcome, leukocytapheresis may be used as part of the management of hyperleukocytosis with or without leukostasis to rapidly reduce the white blood cell (WBC) burden. Since leukocytapheresis only temporarily decreases the WBC count, early initiation of more definite therapy, such as hydroxyurea and/or chemotherapy, is essential. In this article, clinical assessment of the patient's clinical status to determine the need for leukocytapheresis as well as a general guideline for management of the technical aspects and complications of the procedure are discussed.
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Affiliation(s)
- Huy P Pham
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center and the New York-Presbyterian Hospital, New York, New York
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8
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Ganguli A, Sawinski D, Berns JS. Kidney diseases associated with haematological cancers. Nat Rev Nephrol 2015; 11:478-90. [DOI: 10.1038/nrneph.2015.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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9
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Ganzel C, Becker J, Mintz PD, Lazarus HM, Rowe JM. Hyperleukocytosis, leukostasis and leukapheresis: practice management. Blood Rev 2012; 26:117-22. [PMID: 22364832 DOI: 10.1016/j.blre.2012.01.003] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hyperleukocytosis, arbitrarily defined in acute leukemia as a white blood cell count greater than 100,000/mL, often is associated with increased morbidity and mortality in patients with leukemic processes. It can induce leukostasis, tumor lysis syndrome and disseminated intravascular coagulopathy and has significant prognostic implications with or without one of these clinical complications. The main sites that tend to be injured from the obstructions are the central nerve system and lungs. Despite characteristic clinical presentations, the diagnosis of leukostasis is rarely made with high confidence. The main goal of the management of hyperleukocytosis and/or leukostasis is to reduce the white blood cell count before starting induction chemotherapy. The cytoreduction can be achieved by either leukapheresis and/or hyroxyurea. The technical aspects, complications and efficacy of leukapheresis are discussed in the current article.
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Affiliation(s)
- Chezi Ganzel
- Department of Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.
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10
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Kalbani NA, Weitzman S, Abdelhaleem M, Carcao M, Abla O. Acute lymphoblastic leukemia presenting with gross hematuria. Paediatr Child Health 2011; 12:573-4. [PMID: 19030428 DOI: 10.1093/pch/12.7.573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2007] [Indexed: 11/13/2022] Open
Abstract
A case of a six-year-old boy presenting with gross hematuria is reported. Investigations revealed the etiology of the hematuria to be thrombocytopenia in the setting of newly diagnosed acute lymphoblastic leukemia. The diagnosis of leukemia was confirmed by bone marrow examination. The patient's hematuria completely resolved with platelet transfusions. Although thrombocytopenia is a very common presenting feature of acute lymphoblastic leukemia, gross hematuria is exceedingly rare. Thus, thrombocytopenia potentially caused by acute leukemia should be considered in a child presenting with gross hematuria.
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Abstract
Leukemia and lymphoma are the most common and third most common pediatric malignancies, respectively, and share cell lineages, but the clinical and imaging manifestations of these malignancies vary substantially. Along with providing pertinent details on classification, epidemiology, and treatment, this article reviews the current roles of imaging in the management of childhood leukemia and lymphoma, with attention to diagnosis, staging, risk stratification, therapy response assessment, and surveillance for disease relapse and adverse effects of therapy. Advances in functional imaging are also discussed to provide insights into future applications of imaging in the management of pediatric patients with leukemia and lymphoma.
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Affiliation(s)
- R Paul Guillerman
- Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX 77030, USA.
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12
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Acute promyelocytic leukemia treated with idarubicin complicated by focal segmental glomerulosclerosis. J Pediatr Hematol Oncol 2010; 32:e82-4. [PMID: 20048687 DOI: 10.1097/mph.0b013e3181b8473a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors report a 9-year-old boy presenting with a left cerebral ischemic infarction as the first manifestation of acute promyelocytic leukemia. During consolidation chemotherapy, the patient developed nephrotic syndrome and a renal biopsy revealed focal segmental glomerulosclerosis (FSGS). Remission in bone marrow was achieved with chemotherapy, however, new intracranial ischemic areas developed on follow-up. Acute promyelocytic leukemia complicated by FSGS has not been previously reported in children. There may be a relationship between anthracycline treatment and FSGS. Thrombosis could be related with both leukemia and nephrotic syndrome, here thrombosis was the initial symptom, before FSGS was diagnosed.
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13
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Shiber JR, Fines RE. Cerebral hemorrhage due to hyperleukocytosis. J Emerg Med 2009; 40:674-7. [PMID: 19232870 DOI: 10.1016/j.jemermed.2008.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 10/25/2008] [Accepted: 11/15/2008] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph R Shiber
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida 32751, USA
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14
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Amitrano L, Guardascione MA, Schiavone EM, Brancaccio V, Antinolfi I, Iannaccone L, Ferrara F, Balzano A. Hepatic vein thrombosis leading to fulminant hepatic failure in a case of acute non-promyelocytic myelogenous leukemia. Blood Coagul Fibrinolysis 2006; 17:59-61. [PMID: 16607082 DOI: 10.1097/01.mbc.0000198049.19763.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Budd-Chiari syndrome is a rare disease due to occlusion of the hepatic veins often presenting with acute liver failure. Common causes of Budd-Chiari syndrome are chronic myeloproliferative disorders, while acute leukemia has been associated with hepatic vein thrombosis in only two cases in the literature to date. We report a case of Budd-Chiari syndrome complicating a non-promyelocytic acute myelogenous leukemia leading to fulminant hepatic failure.
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De Stefano V, Sorà F, Rossi E, Chiusolo P, Laurenti L, Fianchi L, Zini G, Pagano L, Sica S, Leone G. The risk of thrombosis in patients with acute leukemia: occurrence of thrombosis at diagnosis and during treatment. J Thromb Haemost 2005; 3:1985-92. [PMID: 16102104 DOI: 10.1111/j.1538-7836.2005.01467.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thromboembolism can occur during acute leukemia, especially acute lymphoid leukemia (ALL) treated with L-asparaginase. Yet, most reports are anecdotical and scarce data are available on the risk of thrombosis in acute myeloid leukemia (AML). OBJECTIVES To evaluate the risk of thrombosis in patients with acute leukemia. PATIENTS AND METHODS Three-hundred and seventy-nine consecutive adult patients with newly diagnosed acute leukemia were recruited in an observational cohort study conducted from January 1994 to December 2003. Diagnosis was ALL in 69 patients, acute promyelocytic leukemia (APL; FAB subtype M3) in 31, and non-M3 AML in 279. All first or recurrent symptomatic thromboembolic events objectively diagnosed were recorded. RESULTS Twenty-four patients of the overall 379 (6.3%; 95% CI 4.1%-9.2%) had a first thrombosis, venous in 80% of the cases and arterial in 20%. At diagnosis, thrombosis was a presenting manifestation in 13 cases (3.4% of the whole cohort): 1.4% in ALL, 9.6% in APL, and 3.2% in non-M3 AML patients. Follow-up was carried out on 343 patients without thrombosis at diagnosis and further 11 thrombotic events (3.2%) were recorded. At 6 months from diagnosis, the cumulative incidence of thrombosis was 10.6% in ALL, 8.4% in APL, and 1.7% in non-M3 AML patients. The patients who received L-asparaginase had a 4.9-fold increased risk of thrombosis in comparison with those who did not (95% CI 1.5-16.0). The fatality rate due to thrombosis was 0.8%. CONCLUSIONS In patients with acute leukemia, the risk of thrombosis is not negligible. Thombosis can be a presenting symptom at diagnosis in a significant portion of cases with APL (9.6%) and non-M3 AML (3.2%); a similar rate of thrombosis can occur during the subsequent course of the disease. The incidence of symptomatic thrombosis at diagnosis is relatively low in ALL patients (1.4%), but is significantly increased by further treatment up to 10.6%. Strategies of antithrombotic prophylaxis should be investigated in this setting.
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Affiliation(s)
- V De Stefano
- Institute of Hematology, Catholic University, Rome, Italy.
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Ziegler S, Sperr WR, Knöbl P, Lehr S, Weltermann A, Jäger U, Valent P, Lechner K. Symptomatic venous thromboembolism in acute leukemia. Incidence, risk factors, and impact on prognosis. Thromb Res 2005; 115:59-64. [PMID: 15567454 DOI: 10.1016/j.thromres.2004.07.016] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2004] [Revised: 07/12/2004] [Accepted: 07/28/2004] [Indexed: 11/25/2022]
Abstract
The association between malignant disorders and occurrence of venous thromboembolism is well established. Patients with cancer and venous thromboembolism have adverse prognosis. No systematic study on the incidence and prognostic impact of venous thromboembolism in acute leukemia has been performed as yet. We retrospectively evaluated the incidence of symptomatic venous thromboembolism before chemotherapy in 719 patients (371 males and 348 females, median age of 57.4 years), diagnosed with acute leukemia [534 with acute myelogenous leukemia, 185 with acute lymphoblastic leukemia]. Furthermore, the relationship of venous thromboembolism to clinical and laboratory parameters and its impact on prognosis was assessed. Fifteen patients (2.09%) had venous thromboembolism (objectively confirmed in 13 patients) in close temporal relationship to the onset of acute leukemia. The incidence of venous thromboembolism was the same in acute myelogenous and lymphoblastic leukemia. In five patients, pulmonary embolism was documented. Venous thromboembolism occurred in all subtypes of acute leukemia, but was most common in promyelocytic leukemia. All but one patient were treated with anticoagulants. No patient died from treatment-related bleedings or venous thromboembolism. Overall, survival, disease-free survival, and remission duration did not differ between the patient groups with and without venous thromboembolism. In contrast to solid tumors, venous thromboembolism before or at diagnosis of acute leukemia is not associated with poor prognosis.
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Affiliation(s)
- Sophie Ziegler
- Division of Haematology and Haemostasis, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.
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Orsino A, Schneider R, DeVeber G, Grant R, Massicotte P, Canning P, Carcao M. Childhood acute myelomonocytic leukemia (AML-M4) presenting as catastrophic antiphospholipid antibody syndrome. J Pediatr Hematol Oncol 2004; 26:327-30. [PMID: 15111789 DOI: 10.1097/00043426-200405000-00015] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
: The authors describe a 15-year-old girl presenting with a cerebral ischemic stroke as the first manifestation of catastrophic antiphospholipid antibody syndrome secondary to acute myeloid leukemia (AML). Despite treatment with anticoagulants, therapeutic plasma exchange, and chemotherapy, the patient developed multiorgan thromboses and failure, eventually culminating in death. This unusual presentation of AML has not been previously described in children. Clinical features of antiphospholipid antibody syndrome and current knowledge regarding its association with malignancies are reviewed.
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Affiliation(s)
- Angela Orsino
- Division of Rheumatology, Hospital for Sick Children, Toronto, Ontario, Canada
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Affiliation(s)
- William D Binder
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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20
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Porcu P, Farag S, Marcucci G, Cataland SR, Kennedy MS, Bissell M. Leukocytoreduction for acute leukemia. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:15-23. [PMID: 11886572 DOI: 10.1046/j.1526-0968.2002.00402.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Both in children and adults, acute leukemia may present with extremely high blast counts; a phenomenon known as hyperleukocytosis. Respiratory failure, intracranial bleeding, and severe metabolic abnormalities frequently occur in acute hyperleukocytic leukemias (AHLs) and are the primary determinants of the high early mortality (20% to 40%) observed. The process leading to these complications has long been known as leukostasis, but the biological mechanisms underlying its development and progression have remained unclear. Traditionally, leukostasis has been attributed to overcrowding of leukemic blasts in the microcirculation, and its treatment has focused on prompt leukocytoreduction. However, it is becoming increasingly evident that leukostasis results from the adhesive interactions between leukemic blasts and the endothelium; a mechanism that none of the current therapies directly addresses. The endothelial damage associated with leukostasis is likely to be mediated by cytokines released in situ and by subsequent migration of leukemic blasts in the perivascular space. The adhesion molecules displayed by the leukemic blasts and their chemotactic response to the cytokines in the vascular microenvironment are probably more important in causing leukostasis than the cell number. This may explain why leukostasis may develop in some patients with AHL and not in others, and why some patients with acute leukemia without hyperleukocytosis (<50,000 blasts/mm(3)) develop leukostasis and respond to leukocytoreduction. Leukapheresis effectively reduces the blast count in many patients with AHL and is routinely used for immediate leukocytoreduction. However, the most appropriate use of leukapheresis in acute leukemia remains unclear, and the procedure may not prevent early death more efficiently than fluid therapy, hydroxyurea, and prompt induction chemotherapy. The use of cranial irradiation remains very controversial and is not generally recommended. The identification of the adhesion molecules, soluble cytokines, and chemotactic ligand-receptor pairs mediating endothelial cell damage in AHL should become a priority if better outcomes are desired.
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Affiliation(s)
- Pierluigi Porcu
- Department of Medicine, Division of Hematology/Oncology, Comprehensive Cancer Center, Ohio State University, Columbus, Ohio 43210, USA.
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Porcu P, Cripe LD, Ng EW, Bhatia S, Danielson CM, Orazi A, McCarthy LJ. Hyperleukocytic leukemias and leukostasis: a review of pathophysiology, clinical presentation and management. Leuk Lymphoma 2000; 39:1-18. [PMID: 10975379 DOI: 10.3109/10428190009053534] [Citation(s) in RCA: 184] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acute hyperleukocytic leukemias (AHL) are associated with a very high early mortality rate mostly due to respiratory failure or intracranial bleeding. The pathophysiological process leading to these complications is called leukostasis but the biological mechanisms underlying its development and progression remain unclear. Although traditionally related to "over-crowding" of leukemic blasts in the capillaries of the microcirculation, leukostasis is likely to result from direct endothelial cell damage. This damage is probably mediated by soluble cytokines released during the interaction between leukemic cells and vascular endothelium and by the subsequent migration of leukemic blasts in the perivascular space. Leukemic cell's ability to respond to chemotactic cytokines and their expression of specific adhesion molecules are probably more important in determining whether leukostasis will develop than the number of circulating blasts. This could explain why leukostasis does not develop in all patients with AHL. The identification of the adhesion molecules, cytokines and receptors mediating endothelial cell damage in AHL should become a priority if therapeutic improvements are desired. Leukapheresis is widely used but it is unclear whether it provides additional benefit to a simpler and less invasive intervention with allopurinol, hydroxyurea and intravenous fluids. Cranial irradiation is not generally recommended. Induction chemotherapy should be started without delay. It is hoped that specific pharmacological inhibitors of the interaction between leukemic cells and vascular endothelium will result in an improved outcome for this very high-risk population.
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Affiliation(s)
- P Porcu
- Ohio State University, Columbus, USA.
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