Acute Lymphocytic Leukemia
Initial patient
presentation:
In June 2007, 25-year-old C.H. began to experience symptoms of fatigue and
body pain. She had been studying intensely for a rigorous licensing exam
and was under significant stress. During the two-week period leading up to
the exam, she noticed the appearance of petechiae on her legs, arms, and
stomach, and eventually her entire body. She also noticed the formation of
large bruises all over her body although she had never been prone to
bruising and couldn’t remember any recent injuries. Her symptoms progressed
to where she began to bleed incessantly from her nose and gums. She
developed hemoptysis from the blood originating in her upper respiratory
tract.
Diagnosis:
She presented to the emergency room on a Saturday night, where lab work,
including a complete blood count, was performed. Her WBC count was elevated
(30,000/µL) and her platelets were extremely low (9,000/µL). She
immediately began receiving blood transfusions to restore her platelet
levels. She was monitored closely overnight and on Sunday, she was
transferred to the hospital’s CCU where a bone marrow biopsy was performed.
The results of the biopsy revealed acute lymphoblastic leukemia (ALL) with
the presence of the Philadelphia chromosome. She was later transferred to
another hospital with an inpatient cancer care unit.
Treatment:
Four days later, she began a chemotherapy protocol developed by ECOG
(Eastern Cooperative Oncology Group) that is often used in pediatric cases
of ALL. As part of the protocol, she received high doses of steroids. She
began to experience all the typical side effects of chemotherapy including
nausea, alternating episodes of constipation and diarrhea, alopecia,
mucositis, and fever.
Her second cycle of chemotherapy lasted 5 to 6 weeks. During this cycle,
she developed pneumonia and was given IV antibiotics and had blood cultures
performed. She also received lumbar injections of methotrexate to prevent
the spread of leukemic cells to the spine. She began taking Neupogen® to
stimulate the production of neutrophils since she was very neutropenic. The
third cycle of chemotherapy was more tolerable and involved further
administration of methotrexate.
In January 2008, C.H. received a bone marrow transplant. She remained in
the hospital through February and had daily doctors’ appointments thereafter
through April. The Hickman line that was placed during the transplant
remained in her chest until October 2008 through which she continued to
receive blood transfusions. She developed a series of infections including
the swine flu as a result of her medication-induced immunosuppression.
Outcome:
As of today, C.H. is relatively healthy. She gets lab work done every 6
weeks and a bone marrow biopsy every 6 months. She takes daily oral
medications including: rapamycin and Prograf® (immunosuppressants),
acyclovir, Bactrim®, Tricor®, magnesium and potassium supplements, calcium
and vitamin D (to counteract the osteoporosis caused by steroid use and lack
of reproductive hormones), Femcon®, Ursodiol (to treat elevated liver
enzymes), and Gleevec® (suppresses Philadelphia chromosome).