Aggressive precursor B cell ALL of cervix with obstructive uropathy

Involvement of the cervix with acute lymphoblastic leukaemia (ALL) is extremely rare. In this case report, we discuss an unmarried woman in her early 20s, who presented in the emergency with lower abdominal pain and irregular vaginal bleeding for 1 month. Clinical examination and imaging revealed a large cervical mass probably neoplastic with obstructive uropathy. On evaluation, she was diagnosed incidentally with CALLA-positive precursor B cell ALL in peripheral blood flow cytometry. Involvement of B cell ALL in cervical mass was confirmed by histopathological examination of cervical biopsy and immunohistochemistry markers. Her history was not suggestive of signs and symptoms pertaining to leukaemia. Literature is sparse with only a few cases reporting cervical leukaemic infiltration. The present case report is a rarest case where the primary/initial presentation of precursor B cell ALL was seen with cervical involvement and obstructive uropathy mimicking characteristics of advanced cervical malignancy.

[Blinatumomab as bridging therapy in two children with B-cell acute lymphoblastic leukemia complicated by invasive fungal disease]

This article reports two cases of children with B-cell acute lymphoblastic leukemia (B-ALL) complicated by invasive fungal disease (IFD) who received bridging treatment using blinatumomab. Case 1 was a 4-month-old female infant who experienced recurrent high fever and limb weakness during chemotherapy. Blood culture was negative, and next-generation sequencing (NGS) of peripheral blood, bronchoalveolar lavage fluid, and cerebrospinal fluid were all negative. Chest CT and cranial MRI revealed obvious infection foci. Case 2 was a 2-year-old male patient who experienced recurrent high fever with multiple inflammatory masses during chemotherapy. Candida tropicalis was detected in peripheral blood and abscess fluid using NGS, while blood culture and imaging examinations showed no obvious abnormalities. After antifungal and blinatumomab therapy, both cases showed significant improvement in symptoms, signs, and imaging, and B-ALL remained in continuous remission. The report indicates that bridging treatment with blinatumomab in children with B-ALL complicated by IFD can rebuild the immune system and control the underlying disease in the presence of immunosuppression and severe fungal infection.

Assessment of proxy-reported responses as predictors of motor and sensory peripheral neuropathy in children with B-lymphoblastic leukemia

Chemotherapy-induced peripheral neuropathy (CIPN), a common condition in children with acute lymphoblastic leukemia, can be challenging to diagnose. Using data from Children's Oncology Group AALL0932 physical function study, we sought to determine if parent/guardian proxy-reported responses from the Pediatric Outcomes Data Collection Instrument could identify children with motor or sensory CIPN diagnosed by physical/occupational therapists (PT/OT). Four variables moderately discriminated between children with and without motor CIPN (c-index 0.76, 95% confidence interval [CI]: 0.64-0.84), but sensory and optimism-corrected models had weak discrimination (c-index sensory models 0.65, 95% CI: 0.54-0.74). New proxy-report measures are needed to identify children with PT/OT diagnosed CIPN.

Younger Matched Unrelated Donors Confer Decreased Relapse Risk Compared to Older Sibling Donors in Older Patients with B Cell Acute Lymphoblastic Leukemia Undergoing Allogeneic Hematopoietic Cell Transplantation

Although allogeneic hematopoietic cell transplantation (alloHCT) offers cure for older patients with acute lymphoblastic leukemia (ALL), disease relapse remains a major issue. Whether matched sibling donors (MSDs) are still the preferred donor choice compared to younger matched unrelated donors (MUDs) in the contemporary era of improved transplantation practices remains unknown. This retrospective cohort registry study queried the Center for International Blood and Marrow Transplant Research (CIBMTR) database in patients with B cell ALL (B-ALL) age ≥ 50 years undergoing alloHCT from older MSDs (age ≥ 50 years) or younger MUDs (age ≤ 35 years) between 2011 and 2018. The study included common allograft types, conditioning regimens, and graft-versus-host disease (GVHD) prophylaxis strategies. The primary outcome was relapse risk, and secondary outcomes included nonrelapse mortality (NRM), GVHD, leukemia-free survival (LFS), and overall survival (OS). Among 925 eligible patients in the study cohort, 386 underwent alloHCT with an older MSD (median donor age, 58 years) and 539 underwent alloHCT from a younger MUD (median donor age, 25 year). In multivariable analysis, younger MUDs conferred a significantly decreased risk of relapse (hazard ratio [HR], .68; P = .002) compared with older MSDs. The adjusted cumulative incidence of relapse at 5 years was significantly lower with younger MUDs than with older MSDs (26% versus 37%; P = .001). Younger MUDs were associated with a greater risk of chronic GVHD compared to older MSDs (HR, 1.33; 95% confidence interval [CI], 1.10 to 1.61; P = .003). Compared to older MSDs, younger MUDs conferred an increased NRM (HR, 1.38; P = .02) and higher adjusted cumulative incidence of NRM at 5 years (31% versus 22%; P = .006). There were no differences in post-alloHCT OS or LFS rates between younger MUDs and older MSDs (OS: HR, 1.09; [P = .37]; LFS: HR, .95 [P = .57]). The use of younger MUDs could be considered as a possible way to prevent relapse after alloHCT in older adults with ALL. Combining the use of younger MUDs with improved strategies to reduce GVHD merits further exploration to improve outcomes.

HLH-like toxicities predict poor survival after the use of tisagenlecleucel in children and young adults with B-ALL

Chimeric antigen receptor-associated hemophagocytic lymphohistiocytosis (HLH)-like toxicities (LTs) involving hyperferritinemia, multiorgan dysfunction, coagulopathy, and/or hemophagocytosis are described as occurring in a subset of patients with cytokine release syndrome (CRS). Case series report poor outcomes for those with B-cell acute lymphoblastic leukemia (B-ALL) who develop HLH-LTs, although larger outcomes analyses of children and young adults (CAYAs) with B-ALL who develop these toxicities after the administration of commercially available tisagenlecleucel are not described. Using a multi-institutional database of 185 CAYAs with B-ALL, we conducted a retrospective cohort study including groups that developed HLH-LTs, high-grade (HG) CRS without HLH-LTs, or no to low-grade (NLG) CRS without HLH-LTs. Primary objectives included characterizing the incidence, outcomes, and preinfusion factors associated with HLH-LTs. Among 185 CAYAs infused with tisagenlecleucel, 26 (14.1%) met the criteria for HLH-LTs. One-year overall survival and relapse-free survival were 25.7% and 4.7%, respectively, in those with HLH-LTs compared with 80.1% and 57.6%, respectively, in those without. In multivariable analysis for death, meeting criteria for HLH-LTs carried a hazard ratio of 4.61 (95% confidence interval, 2.41-8.83), controlling for disease burden, age, and sex. Patients who developed HLH-LTs had higher pretisagenlecleucel disease burden, ferritin, and C-reactive protein levels and lower platelet and absolute neutrophil counts than patients with HG- or NLG-CRS without HLH-LTs. Overall, CAYAs with B-ALL who developed HLH-LTs after tisagenlecleucel experienced high rates of relapse and nonrelapse mortality, indicating the urgent need for further investigations into prevention and optimal management of patients who develop HLH-LTs after tisagenlecleucel.

PSEUDOPANUVEITIS AS A HARBINGER FOR SYSTEMIC LEUKEMIA RECURRENCE

PURPOSE

To describe a patient with a history of pre-B-cell acute lymphoblastic leukemia in remission, who developed recurrent alternating intraocular leukemia manifesting with pseudohypopyon, uveal mass, and serous retinal detachment. In multiple instances, this constellation of ocular findings preceded systemic leukemia recurrence.

METHOD

Case report.

RESULTS

A 29-year-old man with a history of pre-B-cell acute lymphoblastic leukemia, in remission after a hematopoietic stem cell transplant, presented with pseudohypopyon, uveal lesions, and serous retinal detachment of the right eye. Comprehensive workup for infectious and inflammatory etiologies was unremarkable, and a bone marrow biopsy revealed systemic recurrence of leukemia. One year later, while again in remission, the patient developed a pseudohypopyon, uveal mass, and serous retinal detachment of the other eye. Repeat bone marrow biopsy showed impending leukemia relapse, which occurred 1 month later. Orbital radiation resulted in complete ocular resolution.

CONCLUSION

The constellation of pseudohypopyon, serous retinal detachment, and uveal mass (pseudopanuveitis) should be recognized as a harbinger for systemic pre-B ALL recurrence.

Management of an Immunocompromised Pediatric Patient With Multiple Hospitalizations for Symptomatic COVID-19

Relapse of infection due to SARS-CoV-2 has been rarely described and there is little guidance regarding the management of such cases in immunocompromised hosts. We present a case of an adolescent female with B-cell acute lymphoblastic leukemia hospitalized multiple times for symptomatic SARS-CoV-2 infection who was safely treated with 2 courses of remdesivir (RDV) and has had no additional readmissions to date. Though additional studies are needed to confirm the safety and efficacy of an additional course of RDV in the setting of relapsed or prolonged severe COVID-19, our observations suggest that a second course of RDV may be considered.

Concurrent Subcutaneous Panniculitis-like T-Cell Lymphoma and B-Cell Acute Lymphoblastic Leukemia in 2 Pediatric Patients

Subcutaneous panniculitis-like T-cell lymphoma is a cutaneous lymphoma characterized by CD8+ T-cell infiltrate in the subcutis that is rare in children. Acute lymphoblastic lymphoma is the most common pediatric malignancy and often presents with fevers and pancytopenia. Herein, we report 2 pediatric patients presenting with subcutaneous panniculitis-like T-cell lymphoma and B-cell acute lymphoblastic lymphoma, distinct hematologic malignancies arising from different lymphoid lineages, with no identifiable germline cancer predisposition.

Hypercalcemia and Disseminated Osteolytic Lesions With Normal Blood Counts and Absence of Circulating Blasts: A Rare Presentation of Childhood B-Lymphoblastic Leukemia

Hypercalcemia and disseminated osteolytic bone lesions are a rare presentation of pediatric acute lymphoblastic leukemia (ALL). The authors report a 3-year-old boy who presented with hypercalcemia and diffuse osteolytic lesions involving axial and appendicular bones. He had normal complete blood count and the absence of blasts in peripheral smear; however, bone marrow aspirate and trephine were consistent with B-cell ALL. A review of the literature highlights the variable clinical outcome of this rare presentation depending on the presence of hypercalcemia and osteolytic lesions with or without chromosomal translocation t(17;19) and coagulation abnormalities. The patient had no coagulopathy and normal karyotype, and showed excellent response to initial treatment in terms of complete remission and negative minimal residual disease after standard-risk induction chemotherapy. Hypercalcemia with diffuse osteolytic lesions warrants bone marrow examination to rule out leukemia even in the absence of any abnormality in complete blood count. The case was reported for awareness of this rare presentation of ALL so that delays can be avoided for this potentially curable but life-threatening disease.

Preemptive mitigation of CD19 CAR T-cell cytokine release syndrome without attenuation of antileukemic efficacy

Immunotherapy with the adoptive transfer of T cells redirected with CD19-specific chimeric antigen receptors (CARs) for B-lineage acute lymphoblastic leukemia (ALL) can salvage >80% of patients having relapsed/refractory disease. The therapeutic index of this emerging modality is attenuated by the occurrence of immunologic toxicity syndromes that occur upon CAR T-cell engraftment. Here, we report on the low incidence of severe cytokine release syndrome (CRS) in a subject treated with a CAR T-cell product composed of a defined ratio CD4:CD8 T-cell composition with a 4-1BB:zeta CAR targeting CD19 who also recieved early intervention treatment. We report that early intervention with tocilizumab and/or corticosteroids may reduce the frequency at which subjects transition from mild CRS to severe CRS. Although early intervention doubled the numbers of subjects dosed with tocilizumab and/or corticosteroids, there was no apparent detrimental effect on minimal residual disease-negative complete remission rates or subsequent persistence of functional CAR T cells compared with subjects who did not receive intervention. Moreover, early intervention therapy did not increase the proportion of subjects who experience neurotoxicity or place subjects at risk for infectious sequelae. These data support the contention that early intervention with tocilizumab and/or corticosteroids in subjects with early signs of CRS is without negative impact on the antitumor potency of CD19 CAR T cells. This intervention serves to enhance the therapeutic index in relapsed/refractory patients and provides the rationale to apply CAR T-cell therapy more broadly in ALL therapy. This trial was registered at www.clinicaltrials.gov as #NCT020284.

Interference of bone marrow CD56+ mesenchymal stromal cells in minimal residual disease investigation of neuroblastoma and other CD45- /CD56+ pediatric malignancies using flow cytometry

BACKGROUND

Bone marrow (BM) samples obtained from minimal residual disease (MRD)-negative children with B-cell acute lymphoblastic leukemia (B-ALL) were used in our laboratory as negative biological controls for the development of a neuroblastoma (NBL) flow-cytometric (FC) protocol. The accidental, but systematic, identification of rare cell populations (RCP) mimicking NBL cells (CD45^- /CD56⁺ ) in these samples indicated the need for their thorough immunophenotypic identification, in order to elucidate their possible interference in NBL-MRD assessment.

PROCEDURE

RCP observed in BM samples from 14 children recovering from BM aplasia due to intensive chemotherapy for B-ALL were investigated with the following markers: CD81, CD200, CD24, GD2, CD73, CD13, CD90, CD146, CD9, CD117, CD10, CD99, and NG2. BM samples from six newly diagnosed patients with NBL and an NBL cell line were simultaneously investigated as positive controls.

RESULTS

The frequency of RCP in B-ALL BM samples was < 1/1 × 10⁴ cells (bulky lysis), and their immunophenotypic profile was indicative of CD56⁺ mesenchymal stromal cells (MSCs) (CD45^- , CD90⁺ , CD146⁺ , CD73⁺ ). Also, RCP expressed CD81 and CD200, simulating NBL cells. The most useful discriminative markers for CD56⁺ MSCs were CD13 and CD73. An appropriate protocol consisting of two tubes with seven color combinations was further proposed: SYTO-16, GD2 (first tube) or CD73 (second tube)-PE, CD24-ECD, CD13-PC5.5, CD45-PC7, CD81-APC, and CD56-APC700.

CONCLUSIONS

RCP that were immunophenotypically similar to NBL were identified as CD56⁺ MSCs. As these cells might pose an obstacle to accurate NBL disease assessment by FC, especially MRD, an enhanced NBL-FC protocol is proposed for prospective evaluation.

Prolonged lumbosacral pain as the initial presentation in acute lymphoblastic leukemia in an adult: A case report

RATIONALE

The differential diagnosis of conditions manifesting as bone and joint pain is complex. Although many individuals with acute leukemia experience bone pain, lumbosacral pain as an early feature of acute lymphoblastic leukemia (ALL) is rare.

PATIENT CONCERNS

Here we report a case of an adult who presented with a 7-month history of persistent lumbosacral pain which had become more severe during the previous month.

DIAGNOSES

Prior to referral, his full blood count revealed no abnormalities, and a computerized tomography scan revealed mild bone hyperplasia of his lumbar vertebrae, with disc herniations of L3-S1. His blood biochemistry and urinary test results had been normal. After referral to our clinic, tests of the morphology, immunology, cytogenetics, and molecular biology of his bone marrow led to a diagnosis of MLL-AF4 fusion positive B-cell ALL.

INTERVENTIONS

Prior to his referral, he had been treated with painkillers by local doctors. The painkillers initially provided pain relief, but their effect wore off over time. After diagnosis, he was started on an adult ALL chemotherapy protocol.

OUTCOMES

His symptoms resolved within a week of starting chemotherapy. At his most recent assessment, 10 months after diagnosis, he was on maintenance chemotherapy and in remission.

LESSONS

This case illustrates that prolonged lumbosacral pain may be a symptom of a life-threatening condition, rather than only attributable to chronic inflammation or disk herniations. Therefore, clinicians need to pay attention to subtle differences in the clinical presentation of patients with lumbosacral pain.

Congenital B-cell Acute Lymphoblastic Leukemia with Congenital Rubella Infection

BACKGROUND

Congenital B-cell Acute lymphoblastic leukemia (ALL) is a rare malignancy.

CHARACTERISTICS

A newborn infant presented with purpuric spots and ecchymotic patches, blueberry muffin rash, depressed neonatal reflexes, respiratory distress and hepatosplenomegaly. Peripheral smear revealed atypical blast cells. Serum ELISA was positive for Rubella IgM and IgG antibodies. Flow cytometry suggested congenital B-cell ALL.

OUTCOME

The baby died after 3 days due to suspected intracranial hemorrhage.

MESSAGE

Congenital leukemia may be rarely associated with congenital rubella infection.

A Case of Renal Involvement in B Lymphoblastic Lymphoma Leukemia

BACKGROUND

Renal involvement is rare in B lymphoblastic lymphoma (B-LBL). The authors describe a rare case of renal involvement in a 21-year-old male patient with B lymphoblastic lymphoma leukemia, presenting with severe lactic acidosis.

METHODS

Hematologic investigation, bone marrow aspirate and biopsy, cytogenetic analysis and renal biopsy were performed.

RESULTS

The patient achieved complete hematological remission (CHR) after induction therapy with the regimen of VDCP and received consolidation chemotherapy regularly. He remained CHR until now.

CONCLUSIONS

Renal biopsy, bone marrow aspirate, and biopsy are important to confirm a correct diagnosis. Renal involvement in B-LBL as a prognostic factor needs further studies.

Hypercalcemia with multiple osteolytic lesions and increased circulating tumor necrosis factor in an adult patient with B-cell acute lymphoblastic leukemia

INTRODUCTION

Acute lymphoblastic leukemia (ALL) is very rarely presented with diffuse osteolytic lesions and hypercalcemia.

CASE OUTLINE

We report a 28-year-old male with the B-cell ALL who presented with extensive osteolytic lesions, bone pain, hepatosplenomegaly, and pancytopenia without circulating blasts in peripheral blood. An increased serum level of tumor necrosis factor (TNF-α) was registered while the levels of IL-1α and IL-1β were normal. The patient failed to achieve remission on two induction regimens but achieved one after the successful allogeneic stem cell transplantation, which lasted for six months, after which he developed a relapse and died.

CONCLUSION

The presented case may serve as a clinical demonstration of possible involvement of TNF-α as a pathogenic factor in the evolution of osteolytic lesions that are occasionally observed in patients with ALL. This might have relevance in the management of such patients as chemotherapy alone may not represent the beneficial option in this clinical context.

Reliability and efficacy of palifermin in prevention and management of oral mucositis in patients with acute lymphoblastic leukemia: a randomized, double-blind controlled clinical trial

BACKGROUND

Myeloablative and hematopoietic stem cells transplantation therapy (HSCT) often acts as side-effect to oral mucositis (OM) with no effective treatment. This randomized-controlled trial analyzed the efficacy of palifermin, administered as a dose during HSCT therapy, as primary prophylaxis on pediatric patients with acute lymphoblastic leukemia (ALL).

METHODS

In this study forty-six patients (9-15 years) with B-cell acute lymphoblastic leukemia (B-ALL) were analyzed. The patients underwent allogenic HSCT conditioned by myeloablative regimen. Subsequently to randomization, patients in the palifermin group were assigned to receive palifermin, 60 mg/kg, intravenously as a single dose 3 days before and after transplant conditioning regimen cycle. The patients in the Control group received only a placebo treatment. Maximum severity of OM, incidence and duration of ulcerative OM, incidence and duration of severe OM limitations were evaluated.

RESULTS

A statistically significant reduction in the incidence of OM up to grade 3 in the palifermin group compared to the control group was discovered. There was also a reduction, confirmed at 60 days, in the degree of severity of mucositis in the palifermin group, with an average of 1.54 grade in the palifermin group, and of 2.16 in the Control group and in the use of opioid analgesics.

CONCLUSIONS

This study indicates that a single dose of palifermin used as primary prophylaxis during HSTC therapy can prevent severe OM in pediatric patients with ALL and used as secondary prophylaxis can prevent the recurrence of severe OM in high-risk patients with previous mucosal injury and improves the quality of life in pediatric patients with ALL.

Renal Presentation in Pediatric Acute Leukemia: Report of 2 Cases

Renal enlargement at time of diagnosis of acute leukemia is very unusual. We here in report 2 pediatric cases of acute leukemia who had their renal affection as the first presenting symptom with no evidences of blast cells in blood smear and none of classical presentation of acute leukemia. The first case is a 4-year-old girl who presented with pallor and abdominal enlargement. Magnetic resonance imaging showed bilateral symmetrical homogenous enlarged kidneys suggestive of infiltration. Complete blood picture (CBC) revealed white blood count 11 × 10⁹/L, hemoglobin 8.7 g/dL and platelet count 197 × 10⁹/L. Bone marrow aspiration was performed, and diagnosed precursor B-cell ALL was made. The child had an excellent response to modified CCG 1991 standard risk protocol of chemotherapy with sustained remission, but unfortunately relapsed 11 month after the end of therapy. The second child was 13-month old, presented with pallor, vomiting, abdominal enlargement, and oliguria 2 days before admission. Initial CBC showed bicytopenia, elevated blood urea, creatinine, and serum uric acid, while abdominal ultrasonography revealed bilateral renal enlargement. Bone marrow examination was done and showed 92% blast of biphenotypic nature. So, biphynotypic leukemia with bilateral renal enlargement and acute renal failure was subsequently diagnosed. The patients admitted to ICU and received supportive care and prednisolone. Renal function normalized and chemotherapy was started. The child achieved complete remission with marked reduction of kidney size but, unfortunately she died from sepsis in consolidation phase of therapy. This case demonstrates an unusual early renal enlargement in childhood acute leukemia. Renal involvement of acute leukemia should be considered in child presenting with unexplained bilateral renal enlargement with or without renal function abnormalities and bone marrow examination should be included in the workup.

Erdheim-Chester disease with rare radiological features in a 14-year old girl with pre-B Acute Lymphocytic Leukemia and Diabetes Mellitus

We report a case of a 14 year-old girl with Diabetes Mellitus who was in remission with pre-B cell Acute Lymphoblastic Leukemia and subsequently diagnosed with Erdheim-Chester disease. Erdheim-Chester disease is a non-Langerhans cell histiocytosis and is very rare in children. In addition, the radiological features of the lesions are atypical and have not been reported in children. There is no known association between the three conditions and this is the first reported case in the literature. A literature review of Erdheim-Chester disease will be performed.

Bone marrow involvement is not manifest in the early stages of childhood acute lymphoblastic leukaemia

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) in children may have atypical presentations causing diagnostic delay. Guidelines for prompt referral have been published. The utility of the specified criteria is unknown.

MATERIAL AND METHODS

Symptoms, signs and laboratory findings at the time of diagnosis were reviewed in a consecutive series of 100 children with ALL in order to determine the frequency of atypical features and to evaluate the Danish referral guideline.

RESULTS

Only 36% had involvement of all three haematopoietic cell lines, and 23% presented with the classic clinical triad of pallor, fever and purpura. Symptoms of bone marrow insufficiency had been present in 77% for an average of two weeks as a late occurrence following musculoskeletal pains (in 49%, duration eight weeks) and constitutional symptoms (in 82%, duration four weeks). Organ infiltration was manifest in 71%. In 22%, only one or no cell count was abnormal; in this group, musculoskeletal symptoms were more frequent and symptom duration longer (two months versus one month). In 15%, lymphoblasts could not be detected in the blood. At the time of diagnosis, the Danish criteria for accelerated investigation were fulfilled in 98% of cases.

CONCLUSION

The clinical presentation of ALL is variable, and full-blown bone marrow insufficiency is a late occurrence as the disease progresses. Reduction of the diagnostic interval requires meticulous examination for organomegaly and attention to subtle haematologic changes.

FUNDING

Not relevant.

TRIAL REGISTRATION

Not relevant.

Mannose binding lectin and ficolin-2 polymorphisms are associated with increased risk for bacterial infections in children with B acute lymphoblastic leukemia

BACKGROUND

We aimed to investigate whether the presence of mannose binding lectin (MBL2), ficolin 2 (FCN2) polymorphisms or the combined deficiency significantly influence the risk and subsequently the frequency of chemotherapy-induced bacterial infections in children with B acute lymphoblastic leukemia (B-ALL).

PROCEDURE

MBL2 polymorphisms for exon 1 and FCN2 polymorphisms for promoter regions -986, -602, -557, -64, -4 and exon 8 regions +6,359, +6,424 were determined in children with B-ALL. FCN2 haplotype was determined by gene sequencing. Number and duration of FN episodes as well as number of bacterial infections were recorded during induction chemotherapy.

RESULTS

Forty-four children with B-ALL (median age 4.3 years, 65.9% males) suffered from 142 FN episodes and 92 bacterial infections (40.2% Gram positive and 59.8% Gram negative). MBL2 low-risk genotype was found in 59.1%, medium-risk in 31.8% and high-risk in 9%. FCN2 low-risk haplotypes were detected in 38.2%, medium-risk in 44.1% and high-risk in 17.6%. MBL2 genotype and FCN2 haplotype were not associated with increased frequency of FN episodes. MBL2 medium/high-risk genotype and FCN2 medium/high-risk haplotype were associated with prolonged duration of FN (P = 0.007 and P = 0.001, respectively) and increased number of bacterial infections (P = 0.001 and P = 0.002, respectively). The combined MBL2/FCN2 medium/high-risk genotype was associated with an increased number of bacterial infections (P = 0.001).

CONCLUSIONS

MBL2 and FCN2 single or combined deficiencies are associated with increased duration of FN episodes as well as increased number of bacterial infections in children with B-ALL suggesting a prognostic role of these genes.

[Hypereosinophilic syndrome as paraneoplastic presentation in an adolescent]

Hypereosinophilic syndrome is characterized by peripheral eosinophilia over 1,500 cell/mm3 and/or tissue eosinophilia, with dysfunction or damage to organ, once other causes were ruled out. This paper presents a case of hypereosinophilic syndrome (HS) which presented as lymphoblastic leukemia in a teenager. This is a 13 year old female, with B cell lymphoblastic leukemia at 9 years old, who received chemotherapy for 2 years achieving remission. One year after remission she presented malar rash, hair loss, arthralgias, conjuntival redness, dyspnea and thoracic oppression. The initial blood count only showed hypereosinophilia, and a bone marrow biopsy did not show blasts and had a negative immunophenotyping. Autoantibodies were negative, except for ANA (1:1,280 in one determination after one negative), complement was normal, lupic band in skin was negative for complement and immunoglobulins; serum IgG 2,195 mg/dL, IgA 231, IgM 327, IgE 109 U/mL; skin testing for aeroallergens and food allergens were negative. Prednisone was started at 1 mg/kg. Abdominal ultrasound only reported biliary sludge flow and hepatosplenomegaly; chest tomography showed centrolobullar interstitial pattern, suggesting eosinophilic pneumonitis. The patient started with a generalized dermatosis, and a biopsy reported leucocytoclastic vasculitis. Six months after the onset of symptomatology there were generalized malaise, uncontrolled fever, gingival haemorrhage, asthenia and adynamia; a blood cell count reported blasts, and bone marrow smear confirmed the diagnosis of cell B lymphoblastic leukemia. The patient deteriorated rapidly showing signs of respiratory difficulty and acute pulmonary edema, therefore chemotherapy was started without response, and finally the patient died. There are several causes of HS, yet one of the least frequent presentations in childhood is the association with neoplasms.

[Arthritis: an unusual and anticipatory clinical presentation of pediatric acute lymphoblastic leukemia. A case report]

BACKGROUND

Acute lymphoblastic leukemia initially shows osteoarticular manifestations. However, it is rare that it shows juvenile idiopathic arthritis (JIA) symptoms.

CLINICAL CASE

A child with acute lymphoblastic leukemia initially misdiagnosed with malignant neoplasia and septic arthritis, and later on with juvenile idiopathic arthritis. The child had persistent articular pain and swelling despite treatment. Six months later, a full blood count revealed leukopenia and neutropenia with lymphocytosis. A bone marrow aspirate confirmed pre-B acute lymphoblastic leukemia with hypodyploidia.

CONCLUSION

This case initially showed typical signs of arthritis, and a diagnosis of acute lymphoblastic leukemia was ruled out, since the those clinical features and hematologic alterations characterizing this hematologic neoplasia.

Precursor B-lymphoblastic lymphoma involving an intracardiac mass and myocardial infiltration: a case report

We report the case of a 17-year-old man with precursor B-lymphoblastic lymphoma involving an intracardiac mass and myocardial infiltration. Intensified chemotherapy followed by autologous peripheral blood stem cell transplantation resulted in long-term complete remission for over 5 years. As the most frequent sites of B-lymphoblastic lymphoma involvement are the skin, soft tissue, bone, and lymph nodes, reports of cases harboring cardiac involvement are relatively few. This is a rare case of B-lymphoblastic lymphoma displaying cardiac involvement, in which cardiac infiltration was one of the initial manifestations.

Fatal neutropenic enterocolitis due to clostridium septicum

We describe a case of Clostridium septicum enterocolitis in a patient with pre-B acute lymphoblastic leukaemia undergoing autologous stem cell transplant. In the setting of neutropenia, Clostridium septicum should be suspected in patients who develop signs and symptoms of acute abdomen.

MDCT evaluation of cardiac involvement in hypereosinophilic syndrome: differentiating mural thrombus, infarcted, and noninfarcted myocardium by delayed-phase scanning

Hypereosinophilic syndrome is a rare disease that can cause multiple-organ damage. Cardiac involvement, which presents as myocardial necrosis, infarction, or thrombus formation, is the leading cause of morbidity and death. Here, we present the case of a 17-year-old girl who had hypereosinophilic syndrome with cardiac involvement, which was evaluated by multidetector-row computed tomography. By means of arterial-phase and low-dose delayed-phase scanning, multidetector-row computed tomography clearly identified the mural thrombus and the infarcted and noninfarcted myocardium-which surpassed the performance of echocardiography in tissue characterization. Therefore, we propose that multidetector-row computed tomography could be a useful noninvasive tool for evaluating patients with cardiac involvement of hypereosinophilic syndrome.

A case report of acute lymphoblastic leukemia complicated by lactic acidosis

Type B lactic acidosis (LA) is a distinct form of metabolic acidosis characterized by low blood pH (≤ 7.35) accompanied by accumulation of lactate (blood concentration ≥ 5 mmol/L) (Luft et al. in Am J Clin Pathol 80:484-489, 1983). There are two types of LA that are caused by different mechanisms. Type A is more common, and is caused by the lack of oxygen (tissue hypoxia or hypoperfusion). In this case, impaired cellular respiration leads to lower pH level and at the same time the cells are forced to metabolize glucose anaerobically, which leads to increased production of lactate. The other type, Type B, is relatively rare, and is occasionally found in patients with hematological malignancies, such as leukemia or lymphoma. The molecular mechanism of Type B LA is not fully understood. Here, we report a case of precursor B cell acute lymphoblastic leukemia who initially shows manifestations of Type B LA and bilateral renal enlargement.

[Diagnosis of cryptococcal encephalitis in a patient with mature B-cell lymphoblastic leukemia]

Fungal meningoencephalitides are one of the most menacing infectious complications in hematologic cancer patients in the presence of myelotoxic agranulocytosis. Due to diagnostic difficulties, mortality in these cases can be as high as 100%. The causative agent of cryptococcosis is Cryptococcus neoformans; damage to the brain arachnoid membranes and substance is diagnosed in 70-90% of cases. Unlike bacterial meningitis, the meningeal symptoms typical of cryptococcal meningoencephalitis are not characteristic. The paper gives a case of successful treatment for cryptococcal meningoencephalitis in the presence of agranulocytosis, the diagnosis of which is based on the detection of abnormal MR signal foci by magnetic resonance imaging and identification of the cryptococcal antigen-glucuronoxylomannan in spinal fluid.

Fatal adenovirus hepatitis during maintenance therapy for childhood acute lymphoblastic leukemia

Disseminated adenoviral infection with hepatitis is rare in children undergoing standard chemotherapy. We report on a 3(1/2)-year-old male with fatal adenovirus hepatitis receiving maintenance chemotherapy for acute lymphoblastic leukemia (ALL). Adenoviral hepatitis was proven by histology, viral culture, and PCR in a liver biopsy. Quantitative real-time PCR in the peripheral blood showed adenoviral DNA copy number >10(9)/ml. Despite aggressive supportive care and antiviral treatment with cidofovir, the patient died rapidly due to fulminant liver failure. Diagnostic and treatment options for adenovirus infection remain unsatisfactory for these patients. We propose suggestions for diagnosis and therapy.

Precursor B-cell acute lymphoblastic leukemia presenting with hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome which can be an inherited congenital disorder or can develop secondary to malignancy, infection, or autoimmune disease. Secondary HLH due to malignancy occurs most commonly with T or NK-cell lymphoid neoplasms. HLH with B-cell malignancies is less common and HLH has rarely been described in association with precursor B-cell acute lymphoblastic leukemia (B-ALL). We report three cases of HLH associated with B-ALL and review 17 cases of ALL-associated HLH previously reported in the literature.

PTHrP-independent hypercalcemia with increased proinflammatory cytokines and bone resorption in two children with CD19-negative precursor B acute lymphoblastic leukemia

Hypercalcemia in childhood acute lymphoblastic leukemia (ALL) is rare and occasionally associated with parathyroid hormone-related protein (PTHrP). However, the pathogenesis of PTHrP-independent hypercalcemia remains unclear. We report two children with precursor B ALL who had marked hypercalcemia (15.8 and 16.6 mg/dl, respectively) and disseminated osteolysis. Serum tumor necrosis factor-alpha (TNF-alpha) and IL-6 were markedly elevated, whereas 1,25(OH)(2) vitamin D(3), intact PTH and PTHrP were decreased or undetected. Analysis of urinary deoxypyridinoline (DPY) or bone biopsy of the osteolytic lesion showed an increased bone resorption, and administration of bisphosphonate improved the hypercalcemia. Patients had ALL with immunophenotype positive for CD10, CD34, and HLA-DR but negative for CD19 and obtained remission with chemotherapy. These findings suggest that increased osteoclastic bone resorption via stimulation with TNF-alpha and IL-6 may be mechanism causing PTHrP-independent hypercalcemia in some patients with precursor B ALL lacking CD19 expression.

Pyridoxine and pyridostigmine treatment in vincristine-induced neuropathy

Vincristine is a commonly used antineoplastic drug and frequently causes neurotoxicity. Here the authors report a 4-year-old boy with acute lymphoblastic leukemia in whom vincristine-induced peripheral and cranial neuropathy developed during remission induction therapy. The patient seemed to benefit from pyridoxine and pyridostigmine therapy greatly and this therapy is recommended in patients with severe vincristine-induced neuropathy.

Inpatient Diabetes Mellitus in the Oncology Setting

CASE STUDY

A.B. is a 32-year-old Caucasian man with a significant, 12-year medical history of diabetes mellitus type I as well as a history of hypertension and hypercholesterolemia. He presented to his primary care doctor with blurred vision and was referred to a retinal specialist, who diagnosed hemorhagic and leukemic retinopathy resulting in limited vision. A complete blood count was drawn during the visit with his retinal specialist. The results were abnormal, revealing a white blood cell count of 30,000/mm3, platelet count of 70,000/mm3, and a hemoglobin of 12.2 gm/dl. The peripheral smear showed peripheral blasts. A.B. was referred to a hematologist, who performed a bone marrow aspiration, confirming the diagnosis of pre-B-cell acute lymphocytic leukemia (ALL). Cytogenetic studies revealed positivity for the Philadelphia chromosome and a translocation of genes 4 and 11.

Relapsing B-cell lymphoblastic leukemia in an adult presenting as an infiltrative cardiac mass with tamponade

We present a case of a 51-year-old man with a history of bone-marrow transplantation for acute lymphoblastic leukemia who returned 4 months later with cardiac tamponade. An echocardiogram showed a solid mass encasing the right ventricle (RV). Surgical biopsy of the mass revealed early relapse with lymphoblasts derived from B-cell precursors. We believe that this is the first description of relapsing B-cell acute lymphoblastic leukemia presenting as an intrathoracic mass with direct invasion of the adjacent cardiac structures causing tamponade physiology.

[Primary cutaneous aspergillosis in a leukemic child]

Primary cutaneous aspergillosis is a rare cutaneous disease that usually affects immunodepressed patients of any age. The most common associated disorders in children are leukemias and lymphomas although it can also occur in neonates and preterms due to their intrinsic immunological immaturity. We report the case of a 4-year-old boy diagnosed of acute lymphoblastic leukemia that, during chemotherapy, developed an ulceronecrotic inflammatory cutaneous lesion in the venopuncture area of the left forearm, and whose microbiological culture was positive for Aspergillus flavus.

Disseminated invasive aspergillosis in a patient with acute leukaemia

A 46-year-old previously healthy woman was diagnosed with acute lymphoblastic leukaemia. The induction phase was complicated by alpha-haemolytic streptococcal bacteremia which responded to antibacterial therapy. Subsequently, the patient developed pneumonie due to Chlamydiapneumoniae which responded to macrolides. Following this infection the patient developed recurrent fever and new pulmonary infiltrates were noted. Bronchoscopy was performed and treatment was administered with liposomal amphotericin B (L-AmB, AmBisome) for two days, but was complicated by acute renal failure. Aspergillus fumigatus was cultured from bronchoalveolar lavage fluid [corrected] L-AmB was discontinued and voriconazole and caspofungin were administered. Despite aggressive antifungal therapy the patient developed progressive invasive infection, with central nervous system involvement as well as lesions appearing in the kidneys and liver. The patient died one week following the diagnosis of aspergillosis.

Acute lymphocytic leukemia with eosinophilia: two case reports and a literature review

Acute lymphocytic leukemia (ALL) associated with eosinophilia is a rare occurrence, but a distinct clinicopathological entity. There have been approximately 44 cases reported in the world literature to date. We report 2 previously healthy young men, aged 20 and 32 years, who presented with marked eosinophilia, and were later diagnosed with pre-B ALL. The patients suffered from significant complications related to eosinophil toxicity, including respiratory failure, myocardial infarction, and a cerebrovascular accident during initial hospitalization. They were treated with high-dose steroids resulting in a rapid suppression of the eosinophilia. Both patients also received chemotherapy according to the standard protocol for ALL; unfortunately, case 1 expired within 2 years of diagnosis from complications related to sepsis and multi-organ failure. We also review the literature and compare the demographics, clinical features, and outcomes of several case studies reported.

Immune evasion strategies of pediatric precursor-B acute lymphoblastic leukemia after allogeneic bone marrow transplantation—a case study

Bone marrow transplantation (BMT) is the primary curative option for refractory/relapsed pediatric acute lymphoblastic leukemia. Although post-transplantation relapse remains a frequent cause of transplantation failure, the mechanisms underlying this are poorly understood. In this study, we compared allogeneic T cell stimulation induced by sequentially obtained precursor-B acute lymphoblastic leukemia (ALL) samples from a single patient with overt graft versus leukemia (GVL) activity. We observed a loss of T cell stimulatory capacity by post-transplantation relapse samples and changes in expression of MHC and the costimulatory molecule CD137 ligand. This study suggests that escape from immune mechanisms after withdrawal of immune suppression is important to ALL progression.

CD19 negative precursor B acute lymphoblastic leukemia presenting with hypercalcemia

A 9-month-old infant presented with hypercalcemia and lytic bone lesions. Suspicion for malignancy led to a bone marrow examination, which showed replacement of the marrow by a small round blue cell infiltrate. Flow cytometric analysis of these cells showed an unusual immunophenotype in that these cells were dim CD45, HLA-DR, and CD10 positive, but CD19, CD20, CD79a, and CD34 negative. Southern blotting showed clonal rearrangement of immunoglobulin heavy chain (IgH) which confirmed a diagnosis of precursor B acute lymphoblastic leukemia (ALL). He received supportive treatment with hydration and pamidronate, but had recurrent episodes of hypercalcemia. Once the correct diagnosis of ALL was established, the patient was treated with an infantile ALL chemotherapeutic regimen and the hypercalcemia resolved. This case highlights the usefulness of immunoglobulin gene rearrangement studies in atypical cases of ALL.