Leukaemia in children: Viva

This is a branching oral built to probe the reasoning that holds the risk stratification and the resuscitation-before-diagnosis at the centre, and to expose the candidate who has memorised the headline without the corners. The questions escalate from the framing to the stabilisation, the diagnosis, the risk assignment, and the definitive therapy, with deliberate probes into the pitfalls. [1]

Opening question: framing the problem

The examiner opens with the film and the count and asks how you frame this problem in a single sentence, and what your first priority is. [9]

A strong answer names acute leukaemia with the circulating lymphoblasts, and states that the first priority is the resuscitation of the dangerous elements, the anaemia, the bleeding risk, the neutropenic fever, and the tumour lysis risk. [7]

Model answer. This child has a trilineage cytopenia with circulating lymphoblasts, which is acute lymphoblastic leukaemia until proven otherwise. My first priority is to resuscitate the dangerous elements, and then to confirm the diagnosis with an urgent bone marrow aspirate and trephine biopsy in a specialist centre. [1]

Probe one: the resuscitation

The examiner presses for exactly what you do in the first four hours, and why you choose those blood products. [7]

A strong answer reproduces the three legs. Red cells are transfused for the symptomatic anaemia, given slowly, and all the cellular products are irradiated and leucodepleted to prevent the transfusion-associated graft-versus-host disease. Platelets are held for a count under ten times ten to the nine per litre in the stable child and under twenty in the febrile or the bleeding child. Tumour lysis is prevented with the hyperhydration using an isotonic fluid without potassium, the rasburicase for the high-risk child, and the four-to-six-hourly biochemistry. The febrile neutropenia gets an empiric antipseudomonal beta-lactam within one hour after the blood cultures. [3][7]