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Introduction of the Client

A 16 year old Malay boy, named Mohammad, presented to the emergency department of
General Hospital Malacca on 07 January 2011 at 10:27 AM with fever, joint pain and loss of
appetite. He was accompanied by his mother. His mother said that his fever was on and off
for the last 2 months and with episode of high grade fever for 2 days in a week.
Based on his mother’s statement, Mohammad did not experience bleeding, any cough, upper
respiratory tract and urinary tract infections symptoms and diarrhoea.
Physical Examination
On examination, Mohammad sitting blood pressure was 136/68 mmHg, his pulse rate was
112 bpm and body temperature was 38˚C.
Mohammad was alert, conscious, can speak in full sentences, pale, and not tachypneic. He
has no palpable lymph node. Respiratory has clear and equal air entry, CVS showed Dual
Rhythm No Murmur, abdomen soft, non-tender and a palpable spleen of about 4cm. and his
CNS was grossly weak.
Diagnosis
Based on the clinical investigation and physical examination, Mohammed was diagnosed
with Acute Lymphocytic/lymphoblastic Leukaemia (ALL).
Management Plan
Upon admission, the physician ordered IV Tazocin 4.5G TDS, IV infusion of 2 pint Dextrose
Saline in 24 hours and FBC test for repeat.
Medical History
Two months ago Mohammad was admitted to Hospital Putra, Malacca. His complaint were
tiredness (for 1 month), pale, fever and swelling on both hands. Based on the blood test
results, his physician diagnosed him with acute lymphocytic/lymphoblastic leukaemia. Since
birth he has no other health complaints except the current diagnosis.
Surgical History
No surgical history.
Family History
Mohammad’s father, a pensioner, told to have diabetes mellitus; his mother, a housewife, has
hypertension while the rest of the family are healthy. The family claimed to have no history
of malignancy.

Social History
Mohammad is currently staying with his parents and 1 sister. He is a form 5 student
in one of the government school of Malacca. He loves to play football in school and play
with his friends in the afternoon after class. He also loves to jog before playing any
ballgames. He is the youngest among the 4 siblings in the family, 2 of them are married and
are staying on their own.
Food and Drug Allergies
Mohammad has no known allergies.

Case Study on Acute Lymphocytic Leukemia


Case Study on Acute Lymphocytic Leukemia
Case Study on Acute Lymphocytic Leukemia
ACUTE LYMPHOCYTIC LEUKEMIA (ALL)

Introduction of the Disease


Leukaemia (also known as “white blood”) is a group of chronic malignant disorders of white
blood cells and white blood precursors. It is characterized by replacement of bone marrow by
malignant immature white blood cells, abnormal immature circulating WBCs, and infiltration
of these cells into the liver, spleen, and lymph nodes throughout the body (LeMone and
Burke, 2008).

Physiology Review
Most blood cells are formed in the bone marrow,
(the soft material in the center of most bones)
called stem cells. Stem cells mature into
different kinds of blood cells of which each kind
has special functions:
a. White blood cells (also called WBCs or
leukocytes), help the body fight infections
and other diseases.

b. Red blood cells (also called RBCs or


erythrocytes) carry oxygen from the
lungs to the body’s tissues and take
carbon dioxide from the tissues back to
the lungs. The red blood cells give blood
its colour.

c. Platelets (also called thrombocytes) help form blood clots that control bleeding.

New or immature blood cells are called blasts.


Some blasts stay in the marrow to mature while
some travel to other parts of the body to mature.
When the blood cells grow old or get damaged,
they die, and new cells will form again.
This picture shows how stem cells mature into 2
different types of white blood cells.
a. A myeloid stem cell matures into a
myeloid blast, which further differentiate
into granulocytes, neutrophil, eosinophil
and basophils.

b. A lymphoid stem cell matures into a


lymphoid blast which further differentiate
into lymphoid tissue such as B cells and
T cells.
Leukemias are classified based on how quickly the disease develops and gets worse. It can
be either chronic (which usually gets worse slowly) or acute (which usually gets worse
quickly):

Case Study on Acute Lymphocytic Leukemia


a. Chronic leukemia. It is characterized by an abnormal mature-appearing cell.

b. Acute leukemia. It is characterized by a rapid disease progression and immature


or undifferentiated blast cells. They are aggressive tumors that reach a climax
within few weeks or months.
The types of leukemia also can be grouped based on the type of white blood cell that is
affected, namely lymphoid cells or myeloid cells:
a. Lymphocytic (or lymphoblastic) leukemias involve immature lymphocytes and
their precursor cells in the bone marrow. It also penetrates the spleen, lymph
nodes, CNS and other tissues. Acute lymphoblastic leukemia (ALL) is most
common in children while chronic lymphoblastic leukemia (CLL) affects older
adults.

b. Myeloid (also known as myelogenous, myelocytic or myeloblastic) leukemia.


This involves the myeloid stem cells in the bone marrow, intervening with the
maturation of all types of blood cells, including granulocytes, RBCs, and
thrombocytes. This affects mostly on adult people. Acute myeloid leukemia
(AML) commonly affects in children and young adults and is usually associated
with toxins, genetic disorders and treatment of other cancers. Chronic myeloid
leukemia (CML) on the other hand, affects primarily adults.
Pathophysiology
Acute lymphocytic leukemia (ALL) is characterized by excessive accumulation of
lymphoblasts (immature lymphocytes) in the bone marrow, lymph nodes, and spleen as well

as in the circulating blood and fails to function effectively as normal blood cells to maintain
immunity. Lymphoblasts stop the normal bone marrow production of red blood cells,
platelets and mature leucocytes resulting to thrombocytopenia, leukopenia, and anemia.
Without treatment, the client may die of infection or haemorrhage.

Bone marrow aspirate from a child with


B-precursor acute lymphoblastic
leukemia. The marrow is replaced
primarily with small, immature
lymphoblasts.

In most cases, ALL result from altered


expression of genes whose products contribute to Bone marrow aspirate from a child
the normal development of B cells and T cells. with T-cell acute lymphoblastic
leukemia. The marrow is replaced
80% cases of which results from malignancy with lymphoblasts of various sizes.

Case Study on Acute Lymphocytic Leukemia


transformation of B cells while 20% from T cells. It is most common in children,
representing nearly one third of all paediatric cancer cases. The annual incidence is
approximately 9-10 cases per 100,000
populations in childhood. The peak
incidence occurs in children aged 2-5
years (Wikipedia). In adults, ALL is
rarely seen until late middle age people
where its incidence increases with aging.
Predisposing Factors
The exact cause of leukemia is not clear.
However, few have been associated with
an increased risk of developing the
disease, to wit:
 Radiation: People exposed to very
high levels of radiation are much
more likely than others to get acute
myeloid leukemia, chronic myeloid
leukemia, or acute lymphocytic leukemia.
✔ Atomic bomb explosion (World War II): people, especially children, who survive
during atomic bomb explosions, are at increased risk of leukemia.

✔ Radiation therapy: medical treatment for cancer and other conditions.

✔ Diagnostic x-rays: Exposure to much lower levels of radiation e.g., dental x-rays
and other diagnostic x-rays ( CT scans). However, research study is still on
going to confirm the link of x-rays and leukemia.

 Chemotherapy: Cancer patients treated with certain types of cancer-fighting drugs


sometimes later get acute myeloid leukemia or acute lymphocytic leukemia e.g.,
alkylating agents or topoisomerase inhibitors is linked with a small chance of later
developing acute leukemia.

 Down Syndrome and Certain Other Inherited Disease increase the risk of acute
leukemia.

Clinical Manifestations
Leukemias, like other blood cells, travel through the body where it influences the health and
function of all organs and systems. Symptoms may vary from one person to another,
depending on the number of leukemic cells and where these cells collect in the body. But
generally, manifestation of leukemia results from anemia, infection and bleeding. These
include pallor, fatigue, tachycardia, malaise, lethargy, and dyspnoea on exertion.

Case Study on Acute Lymphocytic Leukemia


Infection may cause fever, night sweats, oral ulcerations, and frequent or recurrent
respiratory, urinary, integumentary or other infections.
Increased bleeding is due to thrombocytopenia.
Other manifestations results from leukemic cell infiltrations, increased metabolism and
increased leukocytes destruction.
✔ Infiltration of the liver, spleen, lymph nodes and bone marrow causes pain and tissue
swelling in the involved areas.
✔ Meningeal infiltration causes increased intracranial pressure that leads to headache,
altered level of consciousness, cranial nerve impairment, nausea and vomiting.
✔ Infiltration of the kidney may affect renal function, with decreased urine output and
increased blood urea nitrogen and creatinine.
✔ Increased metabolism causes heat intolerance, weight loss, dyspnoea on exertion, and
tachycardia.
✔ Destruction of large numbers of WBCs releases substantial amounts of uric acid into the
circulation; uric acid crystals may obstruct renal tubules, causing renal insufficiency.
Table 2. General Signs and Symptoms of ALL

POSSIBLE PRESENTED BY THE PATIENT

Fever Fever

Loss of appetite Loss of appetite

Joint/Bone pain Joint/Bone pain

Weakness Weakness

Spleen enlargement (splenomegaly) Spleen enlargement (splenomegaly)

Hepatomegaly Hepatomegaly

Infection (sepsis) Sepsis

Dyspnoea on Exertion

Bleeding

Anemia Anemia

Headache

Vomiting

Confusion

Visual disturbance

Seizure

Lymphadenopathy

Case Study on Acute Lymphocytic Leukemia


Elevated WBCs Elevated WBCs

Of the signs and symptoms listed above, Mohammad’s only showed fever, loss of appetite,
bone pain, weakness, sepsis, anemia, elevated WBCs and spleen and liver enlargement of
about 4 cm and 5 cm, respectively.
Clinical Investigations
The following clinical investigations are ordered when patient is suspected of leukemia:
 Physical exam: Checks for swollen lymph nodes, spleen, or liver.

 Blood tests: Complete blood count to check the number of white blood cells, red blood
cells, and platelets. Leukemia causes a very high level of white blood cells. It may also
cause low levels of platelets and haemoglobin, which is found inside red blood cells.
 Biopsy: Removal of tissue of the bone marrow in the hipbone or other large bone to look
for cancer cells. It is the only way to know whether leukemia cells are in the bone
marrow. There are two ways how to obtain sample of the bone marrow, some physician
do both at the same time:

1. Bone Marrow Aspiration: The doctor uses a thick, hollow needle to remove samples
of bone marrow.

2. Bone Marrow Biopsy. The doctor uses a very thick, hollow needle to remove a
small piece of bone and bone marrow.

 Lumbar Puncture: A procedure used to collect cerebrospinal fluid from the spinal
column. A long, thin needle is inserted into the lower back below the level of spinal
cord and fluid is aspirated. If the treatment is for CNS, after aspiration of fluid,
chemotherapy is injected into the spinal canal. This procedure is done from time to
time to check if leukemic cells are being killed and to give more doses of
chemotherapy. Sometimes both chemo and radiation therapies are used.

Case Study on Acute Lymphocytic Leukemia


 Chest x-ray: It shows
swollen lymph nodes or
other organs and bones
inside the chest.

For Mohammad, the clinical


investigation were purely blood test
because he himself and his mother
were not keen on bone marrow
aspiration, where his doctor
recommended to do for further
investigation of his case.

Treatment
Patients with acute lymphocytic
leukemia have several treatment
options, e.g., chemotherapy, radiation therapy, watchful waiting, targeted therapy, biological
therapy, and stem cell transplant. If your spleen is enlarged, your doctor may suggest
removal. Sometimes a combination of these treatments is used.
 Chemotherapy. This is the treatment choice of most types of leukemia, with a goal of
eradicating leukemic cells and producing remission. Children with this disease are likely
to be cured and a number of adult patients have high remissions.
Generally, chemotherapy is divided into 2 phases: induction phase therapy and post-
remission therapy.
a. Induction Phase. During this phase drugs doses are high to eradicate leukemic cells
from the bone marrow. A combination of drugs is used such as daunorubin
(cerubidine, an antitumor antibiotic) with vincristine (oncovin, a plant alkaloid) with
prednisone with asparaginase (elspar). These high doses of drug often damage the
stem cells and interfere with the production of normal blood cells but circulating
mature blood cells are not affected because they are no longer dividing. The degree
of bone marrow suppression is influenced by the number of factor e.g., age,
nutritional status; current chronic diseases (impaired liver or renal function, drug
and drug dose and prior treatment.Colony-stimulating factors (CSFs), also called
hematopoietic growth factors, and often are administer to rescue the bone marrow
following the induction of chemotherapy. CSFs are cytokines that regulate the
growth and differentiation of blood cells.

b. Post-remission Therapy. Once remission is achieved, post remission chemotherapy is


continued to eradicate any additional leukemic cells, prevent relapse, and prolong
survival. A single chemotherapy agent, combination therapy or bone marrow
transplant may be used for post remission treatment (LeMone & Burke, 2008).

 Radiation Therapy (also called radiotherapy) uses high-energy rays to kill leukemia
cells. Radiotherapy damages cellular DNA. Though the leukemic cells continue to
function, it cannot divide and multiply e.g., cells in bone marrow and cancer cells divides
rapidly and respond quickly to radiation therapy. Radiotherapy is also aimed at the
spleen, the brain, or other parts of the body where leukemia cells have collected.

Case Study on Acute Lymphocytic Leukemia


 Bone Marrow Transplant (BMT). This is often used in conjunction with chemotherapy
or radiation. There are 2 categories:

1. Allogenic BMT. Uses the bone marrow of a healthy donor (usually from a
sibling/unrelated closed matched antigen. The donor’s bone marrow is aspirated
and is infused through a central venous line into the recipient.

2. Autologous BMT (or bone marrow rescue). Uses the client own bone marrow to
restore the bone marrow function after chemotherapy or radiation. During the
period of disease remission, about 1L of bone marrow is aspirated from the
patient. It is then stored and frozen for use after treatment of chemotherapy or
radiation, with the aim of destroying the immune system and malignant cells and
to prepare space in the bone marrow for new cells. The filtered bone marrow is
thawed and infused intravenously through central line and slowly become part of
the client’s bone marrow, neutrophil count increases, and normal haematopoiesis
takes place.

 Allogeneic Stem Cell Transplant. Is a replacement of the recipients blood cell lines
(WBCs, RBCs, and platelets) with cells derived from the donor stem cells. This is an
alternative to bone marrow transplant. The recipient and the donor tissue must be closely
matched prior to harvesting and necessary procedure and treatment are conducted prior to
harvesting to prevent the risk of infection and other complications.

 Biologic Therapy. Interferon and interleukin (cytokines) may be used to treat leukemias.
They modify the body’s response to cancer cells, moderate immune function and inhibit
abnormal cell proliferation and growth.

Upon admission of the client, he was given Paracetamol for his fever, IV Tezocin 4.5g tds for
his antibiotic and IV infusion of 2 pints normal saline in 24 hours. He was also given a series
of blood transfusion due to low haemoglobin count; however, any of the above treatment
options were not given to the patient.

Table 3. Schedule of Blood Transfusion

Date Time Amount Transfused (ml) Reaction

07.1.2011 7:30 pm 350 No


08.1.2011 7:40 pm 350 No
10.1.2011 7:20 pm 345 No
11.1.2011 7:00 pm 331 No

Table 4. Medication

Name Indications Side Effects

Case Study on Acute Lymphocytic Leukemia


IV Tazocin 4.5mg Treatment of systemic and local Diarrhoea, rashes, nausea,
(TDS) bacterial infection in susceptible vomiting, increased
organisms. Lower the respiratory sweating, weakness, dry
tract infection. mouth, muscle pain.

T. Paracetamol 1g Analgesic. Relief of pain and fever Vomiting, nausea,


(PRN) in adult and children. abdominal pain, anuria,
liver injury, oedema

The physician of Mohammed order treatment of chemotherapy and bone marrow aspiration,
but the patient and his parents refused for the said treatments even after the physician’s
explanations about his illness, its complications e.g., bleeding, infection, coma and death, if
remain untreated and poor prognosis if treatment is delayed. The patient’s mother only
preferred symptomatic treatment and follow up.

Possible Complications

Complications of leukemia and its therapy may differ from one patient to another. The
following are the possible complications:

 Tumor Lysis Syndrome: Rapid destruction of large numbers of malignant cells leads to
alteration in electrolytes (hyperuricemia, hyperkalemia, hyperphosphatemia, and
hypocalcemia).

 Sepsis: Due to low immunity

 Renal Failure: Decreased urine output and increased blood urea nitrogen and creatinine.

 Bleeding (subarachnoid, renal haemorrhage): Due to thrombocytopenia (low platelet


count) leads to bruising, petechiae, bleeding gums, and bleeding within specific organs
and tissues.

 Neuropathy: Infiltration of leukemic cell in the CNS


 Seizure (also called convulsion): Due to increased intracranial pressure. Seizure is a
single event abnormal electrical discharge in the brain resulting in an abrupt and
temporary altered state of cerebral function

 Disseminated Intravascular Coagulation (DIC): A disruption of haemostasis


characteristic by widespread intravascular clotting and bleeding

 Leukostasis: Blood vessel walls are infiltrated and weakened, with high risk of rupture
and bleeding, including intracranial haemorrhage
Until Mohammad was discharge, no complications have been reported.

Case Study on Acute Lymphocytic Leukemia


Case Study on Acute Lymphocytic Leukemia
Case Study on Acute Lymphocytic Leukemia
Case Study on Acute Lymphocytic Leukemia
Discharge Plan

Mohammed was discharge on 12 January 2011. He was alert, conscious but the skin was a
bit pale. His blood pressure was 134/90 mmHg, pulse of 114 bpm, respiratory rate of 20
breath per minute and sPO2 of 100%. He was afebrile and no more complaint of bone pain
and his blood test showed still on the low side. Upon his discharge, his physician and staff
nurses advised him and his mother on how to keep him healthy as possible, how to prevent
himself from getting injury, infection, and what to do if signs and symptoms of illness will
come back again.
A. Follow-up Care

He was advised to come to leukemia clinic in 1 month time for blood test. He was advised
for a regular check-up, necessary to help ensure that any changes in his health are noted and
treated if needed. If any health problems between check-ups are encountered, contact his
doctor immediately or come to the hospital.
Check-up may include a careful physical examination, blood tests, cytogenetic, x-rays, bone
marrow aspiration, or spinal tap, only upon consent is given.
B. Self Help Guide At Home
✔ Diet: Eat a variety of healthy foods from all the food groups e.g., breads, vegetables,
fruits, milk and milk products, and protein (beans, eggs, poultry, meat and fish).
Eating healthy foods may help you feel better and have more energy. You may need
to make diet changes depending on your tolerance. Eat small-frequent meal and
snacks rather than 1 big meal which will only suppress the appetite.

Case Study on Acute Lymphocytic Leukemia


✔ Drink Fluids: Drink about about 2-3 liters of liquid each day or prescribed by doctor.
Choose healthy like water, juices, and milk rather than carbonated drinks. If you are
used to drinking liquids that contain caffeine, such as coffee, these can also be
counted in your daily liquid amount.

✔ Avoid Constipation: Try to keep from getting constipation or diarrhoea. These can
irritate the rectum which can cause infection. Do not try to push the stool out if it is
too hard. Walking is the best way to keep your bowels moving. Eat food high in fiber
e.g. cereals, beans, and whole grain breads. Use fiber medicine or a stool softener as
prescribed by doctors to soften stools and easy excretion.

✔ Rest: Balance activity to the amount of energy you have. Nap a couple of times
during the day. Going to bed early and getting up late may also help.

✔ Exercise: Exercise keeps you healthy. Decrease activities if blood cell count is low
based on the result of blood test. Ask your doctor to help you plan the best exercise
program for you. Start exercising when your doctor says it is OK. It is best to start
slowly and do more as you get stronger.

✔ Avoid Things That Can Cause Cuts Or Bruises: Do not play contact sports since it
may bleed or bruise easily.

A. Preventing Infection
✔ Hand washing. Wash hands after using the bathroom and before eating with correct
hand washing technique.

✔ Shower daily. Keep yourself clean daily to prevent accumulation of microorganisms


on your skin.

✔ Use a deodorant spray instead of antiperspirant. Antiperspirants block sweat


glands which can cause an infection.

✔ Brush teeth two to three times a day. Use soft-bristle toothbrush and gently brush
teeth to avoid bleeding and infection. See your dentist for regular check-ups to detect
and treat dental infection and diseases.

✔ Do not water and take care plants and flowers. Microorganisms are present in
plant dirts and flower vase water.

✔ Perineum care. Clean perineum area properly each time you pass urine and bowel.

✔ Stay away from colds or flu. Stay away from large groups of people this will
decrease chances of getting sick e.g. colds and flu.

✔ Get vaccinated. Get shots of vaccination to keep from getting flu and pneumonia.
A. Avoid Bruises and Bleeding
✔ Beware of bumps and cuts. Do not play contact sports such as football or soccer.

✔ Beware of high altitudes. Do not do any activity that may cause chest pain or
trouble breathing.

Case Study on Acute Lymphocytic Leukemia


✔ Beware of slippery slippers and shoes. Wear non-skid slippers or shoes when are
out of bed and when walking outside especially slippery and wet floors and grounds.
This will keep you away from slipping or falling.

✔ Beware of hard-bristled tooth brush. Use soft-bristled brush to help prevent gum
bleeding. Do not floss teeth while platelet count is low. Do not use tooth picks, it may
prick your gums.

✔ Do not blow your nose hard. It may damage of the mucous membrane increasing
the risk of bleeding.

✔ Use nail clippers or a nail file. Do not use scissors to trim your nails. Use nail file to
smoothened the nails and trim the sides.

✔ Avoid straining during bowel movement. Ask the doctor for stool softeners to
prevent constipation. Walking helps to keep bowels moving.

✔ Beware of Aspirin. Do not take medicine containing aspirin. Aspirin is for thinning
of the blood increasing the risk of bleeding.

✔ Put pressure on the bleeding area. Ice packs cool the area and decrease blood flow.
Put the ice in a plastic bag and cover with towel and place over at the injured area.

A. Seek care immediately if the following is experienced:

✔ Chest pain.

✔ Trouble breathing.

✔ Fever for the last 2 weeks

✔ Signs of minor bleeding, such as petechiae, ecchymosis, conjunctival haemorrhage,


nose bleed, bleeding gums, bleeding at puncture sites.

✔ Be alert for signs of serious bleeding, such as headache with change in


responsiveness, blurred vision, haemoptysis (coughing op of blood), hematemesis
(vomiting of blood), melena, hypotension, tachycardia, dizziness.

Case Study on Acute Lymphocytic Leukemia


Case Study on Acute Lymphocytic Leukemia
Case Study on Acute Lymphocytic Leukemia
Case Study on Acute Lymphocytic Leukemia
Case Study on Acute Lymphocytic Leukemia
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Case Study on Acute Lymphocytic Leukemia