Difference between revisions of "Leukemia (peds)"

(Hyperleukocytosis)
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==Clinical Features==
 
==Clinical Features==
 
===Bone marrow infiltration and failure===
 
===Bone marrow infiltration and failure===
*Pallor, fatigue, easy bleeding, [[fever]], infection
+
*Pallor, [[fatigue]], easy bleeding, [[fever]], infection
*Bone/joint pain
+
*Bone pain/[[arthralgia]]
*Hepatomegaly or splenomegaly
+
*[[Hepatomegaly]] or splenomegaly
  
 
===[[Leukostasis and hyperleukocytosis|Hyperleukocytosis]]===
 
===[[Leukostasis and hyperleukocytosis|Hyperleukocytosis]]===
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==Differential Diagnosis==
 
==Differential Diagnosis==
 
''Leukemias will often involve >1 cell line; other conditions restricted to single line''
 
''Leukemias will often involve >1 cell line; other conditions restricted to single line''
*Aplastic anemia
+
*[[Aplastic anemia]]
*Iron deficiency anemia
+
*Iron deficiency [[anemia]]
*Viral infection (EBV, CMV, Parvo)
+
*Viral infection ([[EBV]], [[CMV]], Parvo)
*Immune thrombocytopenia
+
*Immune [[thrombocytopenia]]
 
*Rheumatologic diseases
 
*Rheumatologic diseases
  
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*CBC with manual differential
 
*CBC with manual differential
 
**If suggestive of leukemia also order:
 
**If suggestive of leukemia also order:
***Chemistry, Ca, Phos, Mg, Uric acid, LFT, LDH, coags, T+S, UCG (if applicable)
+
***Chemistry, Ca, Phos, Mg, Uric acid, [[LFTs]], LDH, coags, T+S, UCG (if applicable)
 
***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
 
***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
***CXR
+
***[[CXR]]
  
 
==Management==
 
==Management==
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**Leukocyte-reduced: for patients likely to receive multiple RBC or platelets in future
 
**Leukocyte-reduced: for patients likely to receive multiple RBC or platelets in future
 
**CMV seronegative: for <1yr old, if might need bone marrow transplant in future
 
**CMV seronegative: for <1yr old, if might need bone marrow transplant in future
*Anemia
+
*[[Anemia]]
 
**10 cc/kg of [[pRBCs]] raises hemoglobin by 3 gm/dL
 
**10 cc/kg of [[pRBCs]] raises hemoglobin by 3 gm/dL
 
**Raise hemoglobin to >8
 
**Raise hemoglobin to >8
 
*[[Thrombocytopenia]]
 
*[[Thrombocytopenia]]
**0.1 unit/kg results in 30-50K increase in platelet count
+
**0.1 unit/kg [[platelets]] results in 30-50K increase in platelet count
 
**Risk of spontaneous ICH is extremely low until platelets <5K
 
**Risk of spontaneous ICH is extremely low until platelets <5K
 
**Transfuse if:
 
**Transfuse if:
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***Invasive procedures require platelets >50K
 
***Invasive procedures require platelets >50K
  
===Hyperleukocytosis===
+
===[[Hyperleukocytosis]]===
 
*Aggressive IV hydration
 
*Aggressive IV hydration
 
*Urinary alkalinization (pH 7-7.5)
 
*Urinary alkalinization (pH 7-7.5)
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==Disposition==
 
==Disposition==
 +
*admit
  
 
==See Also==
 
==See Also==
 +
*[[oncologic emergencies]]
  
 
==References==
 
==References==

Revision as of 22:51, 30 August 2019

Background

  • Most common cancer in children (33% of all malignancies)

ALL

  • 3/4 of pediatric leukemias
  • 5-year survival 75%-80%
  • Peak incidence 3-5yr old

AML

  • 1/5 of pediatric leukemias
  • Worse prognosis
  • More complications (more intense chemo treatment required)

Clinical Features

Bone marrow infiltration and failure

Hyperleukocytosis

Differential Diagnosis

Leukemias will often involve >1 cell line; other conditions restricted to single line

Evaluation[1]

  • CBC with manual differential
    • If suggestive of leukemia also order:
      • Chemistry, Ca, Phos, Mg, Uric acid, LFTs, LDH, coags, T+S, UCG (if applicable)
      • Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
      • CXR

Management

Transfusion

  • Options
    • Irradiated: for very immunosuppressed (to prevent graft vs host)
    • Leukocyte-reduced: for patients likely to receive multiple RBC or platelets in future
    • CMV seronegative: for <1yr old, if might need bone marrow transplant in future
  • Anemia
    • 10 cc/kg of pRBCs raises hemoglobin by 3 gm/dL
    • Raise hemoglobin to >8
  • Thrombocytopenia
    • 0.1 unit/kg platelets results in 30-50K increase in platelet count
    • Risk of spontaneous ICH is extremely low until platelets <5K
    • Transfuse if:
      • Asymptomatic with platelets <10K
      • Invasive procedures require platelets >50K

Hyperleukocytosis

  • Aggressive IV hydration
  • Urinary alkalinization (pH 7-7.5)
  • Allopurinol (for Tumor Lysis Syndrome (TLS))
  • Avoid diuretics and pRBC transfusion (platelets ok)
  • Give platelets if <20K
  • Leukapheresis

Disposition

  • admit

See Also

References

  1. Horton TM and Steuber CP. Overview of the presentation and diagnosis of acute lymphoblastic leukemia in children and adolescents. UpToDate.