Leukaemia in children: Case

Framing the case

This four-year-old boy has the classic presentation of acute lymphoblastic leukaemia. The trilineage cytopenia, the circulating lymphoblasts, the organomegaly and the lymphadenopathy, alongside the three-week history of the pallor, the bruising and the fever, together make a marrow malignancy the working diagnosis, and the first decision is to move the child from an elective workup to an emergency resuscitation. The framework that organises the case is the recognition that this is a clonal lymphoid malignancy, and the first priority is the resuscitation before the diagnosis is pursued. ^[9][1]

Immediate assessment and stabilisation

The assessment begins with the airway, the breathing and the circulation, because a child with a severe anaemia, a bleeding risk and a fever is in danger before any diagnosis is reached. The child is admitted to a paediatric haematology-oncology centre, and the resuscitation rests on the three legs. Red cells are transfused for the symptomatic anaemia, given slowly to avoid the circulatory overload, with all the cellular products irradiated and leucodepleted to prevent the transfusion-associated graft-versus-host disease. Platelets are transfused for the count under twenty times ten to the nine per litre in this febrile child. ^[7]

Tumour lysis prophylaxis begins before the first chemotherapy dose, with the hyperhydration using an isotonic fluid without potassium, the rasburicase for the high-risk child, and the four-to-six-hourly biochemistry of the potassium, the phosphate, the calcium, the creatinine and the urate. The glucose-6-phosphate dehydrogenase status is checked before the rasburicase because it is contraindicated in the deficiency. The blood cultures are drawn and an empiric antipseudomonal beta-lactam such as the piperacillin-tazobactam is given within one hour for the febrile neutropenia, with a neutrophil count under zero point five times ten to the nine per litre. ^[3][7]