Cetak Final 9 Okt 2019

LONGITUDINAL CASE
Acute Lymphoblastic Leukemia - L II (C91.00),
Severe Neutropenia (D70.3), Febrile Neutropenia (D70.9),
Severe Anemia (D61.9), Pneumonia (J18.9),
Marasmic Type Malnourishment (E41), Acute Diarrhea without
Dehydration (R19.7), Acute Tonsilitis (J03.90)
By:
Nindy Resti Rahayu, MD
Local Evaluation
Malang, October 10th 2019
Longitudinal Case-Local Evaluation, Malang October 10th, 2019 1

INDONESIAN PEDIATRIC SOCIETY
Identiy
Name : Nindy Resti Rahayu
NIM : 158070900111003
Date of entry as resident : July, 1st 2015
Regional board date : October 10th 2019
Patient Identity
Name : MI
Sex : Male
Date of Birth : June 18th, 2006
Address : Malang
Medical Record No. : 11457052
Date of Hospitalization : October 1st, 2019
The Commencement : October 3st, 2019

of Hospital Admission
Parents Identity
Father : Mother:
Name : Mr. R Mrs.A
Age : 35 years-old 30 years-old
Education : Senior High School Junior High School
Occupation : Farmer Farmer
Religion : Moslem Moslem
Address : Dsn. Surorowo RT1/6 Kayukebek, Tutur, Pasuruan
CASE SUMMARY

Chief Complaint : Pallor (heteroanamnesis and autoanamnesis with parents
and patient)
Present Medical History

Patient looked pallor in the last two months and getting worse in a week
before admission. Pallor was seen on both of palms and feet. There is no history
of spontaneous bleeding, epistaxis, gum bleeding, dark color stool or trauma, but
he had reddish spot in both of feet and hands since two weeks before admission.
Patient complained of a mass in the left neck since 3 months prior to
admission. Mass consistency was hard, well defined, fixed, and no pain. Mass
has gotten bigger since two months before admission. Mass became multiple and
spread to the right neck, armpits, and inguinal since one month before admission.
Patient also complained of shortness of breath since a week before
admission. It worsened a day before admission and characteristized by rapid
breathing and nasal flaring. Patient also complained with cough since one week
before admission. His father is an active smoker. Patient school at pesantren and
he has nine person roommate.
Patient suffered from recurrent fever with the highest temperature at 38 o C
since 2 months ago. Fever temporarily relieved with oral paracetamol. The last
three days before admission the temperature raising until 39 o C accompanied
with sore throat.
Patient suffered from diarrhea since one week before admission. The
frequency was seven times a day with loose consistency, there was no mucus
and blood. Patient had decrease of appetite in the last three months, and only ate
porridge. He also suffered from sore throat since three days before admission.
His mother said that he became thinner since three months before admission.
There was no history of vomiting. The urinary frequency was in normal limit and
the urinary colour was yellow and clear.
History of Medicine

Last month before admission, patient already hospitalized in this general
hospital with the same complaint. He got several blood transfusion and admitted
for a week. Bone marrow puncture was performed with result acute lymphoblastic
leukemia. Chemotherapy was planned to be given after a week of oral prednison
regularly. After a week of oral prednison, patient never come to hospital.
Past Medical History
In Agustus 2019 patient admitted in private hospital with chief complaint
pallor and fever. Because there was no improvement after a week of treatment,
patient was reffered to this public general hospital. Patient got blood transfusion
several times. He got bone marrow puncture examination with result acute
lymphoblastic leukemia (ALL) in September 3rd, 2019 and was planned to have
chemotherapy. Oral prednison already given for one week but after discharged
patient never control to hospital due to the economical problem.
Family History
No history of cancer and tumor in his family. No family with the same
complaint as patient. There were four persons who live in one house. This is the
first marriage of mother and first marriage of father. Both of parents work as
farmer. He was the oldest from the two siblings. He has 4 year-old sister and she
never get sick before.

13 years
Figure 1. Family Tree
Maternal History & Antenatal Care

The mother was about 16 years-old when she was pregnant. Which was
her first pregnancy. The patient’s mother routinely controlled her pregnancy to
midwife. She had routine antenatal care at private midwife every months. She
had no history of diabetes melitus, hypertension, vaginal discharge, frequent
urination and bleeding. There was no history of fever and skin rash during
pregnancy. Mother had never consumed alcohol nor partially cooked food, she
consumed a wide variations of food, a dish of rice, vegetables, tofu, tempe, fish
and meat with frequency 3 times per day. There is no pet in patient’s house. She
still worked as farmer as during pregnancy and often exposed to pesticides.

Birth and Delivery History
The patient was born spontaneously by the midwife in 2006 with
birthweight about 3200 grams but the mother did not know the length of the baby.
At delivery, the baby cried directly, no breathing problem, no seizure, no
yellowish eye or skin. There is no history of hospitalization after birth.
Conclusion: the history of pregnancy had risk factor exposed to pesticides and
delivery was normal.
Growth and Development History

Patient growth
Patients are cared by mother and father from birth. Mother doesn't have a
KMS book. She forgets to record the weight and height of the patient. At birth, the
patient's birth weight was 3200 grams, body length and head circumference is
unknown. Monitoring body weight, body length / height, and head circumference
is not done well and the patient's mother forgets to remember. The body weight
of the patient was 45 kgs (three months before admission). According to mother
patient suffered from loss body weight about 10 kgs in three months. Mother
does not pay attention to patient’s height, she only said that he doesn’t look
shorter compare to his friend.
Patient development
According to his mother, patient started to lift his head at the age of 3
months-old, sit without support at the age 6 months-old, stand alone at the age
11 months-old, and walk well at 12 months-old. Now the patient was on 2nd grade
of junior high school and he did well in academics.
Table 1. Development of patient
Gross motoric Fine Motoric-Adaptive
Head up 900 : 3 months-old
Sit-no support : 6 months-old
Stand alone : 11 months-old

Walk well : 12 months-old
Language Personal-Social
One word : 10 month-old Smile spontaneously : 3 months-old
Two Word : 12 months-old Wave Bye-bye : 9 months-old
Combine Word : 18 months-old Put on clothing : 24 months-old
Conclusion: The growth and development was normal compared to his peer group.

Immunization History
The patient had BCG, DPT, Polio, Hepatitis B, and measles immunization
according to the Ministry of Health’s program before 1 year old. The patient’s
medical record was lost. The patient had given immunization at school. His last
immunization was Measles Rubella (MR) and Diphteria immunization.
Table 2. Patient Immunization Timetable
Age / 1 2 3 4 9 6 7 8
Immunization month month Month month Month years years years
BCG 
DPT   
Polio    
Hepatitis B    
HIB   
Measles  
DT   
TT   
Conclusion: Basic immunization according to Ministry of Health’s program was complete.
Nutritional History
Patient had breastfed from birth until 24 months age without any
additional formula milk. Patient fed baby porridge since 3 years old. The patients
started to be given solid food since 6 months of age, steamed rice from 10
months of age, and rice from 11 months of age with variable dishes like tempe,
tofu, egg and vegetables. The patients eat three times a day, a plate of rice each
portion. Since two months before admission patient suffered from decrease of
appetite and only eat porridge three times a day, the amount is half of plate each
times. He drinks cows milk two times a day, each 200 ml.

Social Economic Background
Patient is the first child in his family. His father was 35 years-old,
Javanese ethnics, moslem, with his last education was senior high school. He
worked as a farmer. The mother was 30 years-old, Javanese ethnics, moslem,
with her last education was junior high school graduate. Her mother works as a
farmer. So far, patient treatment financed by government’s health insurance.
Figure 2. View of environment surroundings of patient.

Notes: Figure A, B and C. Picture of the main road and the patient’s home entrance. D.
Wali Songo boarding school around 70 kilometers, talking about 1,5 hour from the
patient”s house E. Public health center around 6 kilometers, taking about 15 minutes from
the patient’s house. F. The right side view of the patient's house is a vegetable garden. G
Mosque around 100 meters from patient’s house. H, I. Back view of the patient's house
there is a cow shed.

Figure 3. View of house of patient.
Notes: J. Front view (The width of the house is approximately 6 meters in width, 12
meters in length and has only one floor, it has brick wall painted and ceramic floor). K.
Living room with sufficient ventilation. L. Family room. M. patient bedroom N. Kitchen. O.
Bathroom.
Patient has lived in a house with his family. The house is inhabited by 4
persons (patient’s father, patient’s mother, patient’s sister and the patient
himself). The width of the house is approximately 6 meters in width, 12 meters in
length consisting of 1 living room and family room 2 bedrooms, 1 dining room, 1
kitchen and bathroom. The guest room and family size is 3x6 m. The family room
is 3x3 m. House has tile floor, wall, roof tile, and ceramic installed on the entire
floor with sufficient ventilation and lighting (there is a window in each room). The
patient have roommate (his sister).
The neighbourhood area is a densely populated area. There has been a
good relationship among neighbours. They have no problem in neighbouring
social life. Public facilities are affordable, the right side view of the patient's house
is a vegetable garden. Mosque around 100 meters from patient’s house. Public
health centre is around 6.5 kms and takes about 20 minutes to get there from
patient’s house by motorcycle, while the patient’s school is also around 70 kms
from the patient’s house.
Conclusion: well social economic, well hygiene and sanitation household.

PHYSICAL EXAMINATION OCTOBER 1st 2019
(at Emergency Ward, General Hospital)
Antropometric Status
Weight for Age : 35 kgs ( P3 to P10 )
Heigth for Age : 155 cms ( P25 to P50) ~ 13 years old
Upper Arm circumference : 18 cms ( <P5 )
Head Circumference : 52.5 cms ( -2 SD to mean)
Ideal body weight : 45 kgs
% Ideal body weight : 77 %

IMAM
Figure 4. Graphic weight for age percentiles and stature for age percentile
Description : Patient weight is 35 kgs (P3-P10) and his height is 155 cm (P50) equal with
13 years old

Figure 5. Arm circumference for male
Description : Upper arm circumference of the patient is 18 cms (< P5)
Figure 6. Head Circumference of the patient is 52.5 cm (-2 SD until Mean)

Figure 7. Blood Pressure of the patient 100/70 mmHg. Systole (P50-P90) and
dyastole (P50)

Physical
Description
Examination
General Fully conscious, pale (+),normocephalic, icteric (-), dyspnea (+), look
appearance painless, cyanotic (-), edema (-)
Vital sign GCS 456, heart rate 91 x/min, strong pulse, regular; Respiratory rate 30
x/min,spontaneous breathing; Axillar temperature 39 o C, Blood pressure
100/70 mmHg. SaO2 99% with O2 nasal canule 2 lpm.
Head Normocephalic. The color of hair was black, not easily fall out, sign of
trauma (-)
Face : Symetrical, edema palpepbra (-), old man face (+)
Eyes : Symetrical eye ball movement, not
exopthalmic,conjunctiva anemic, sclera not icteric,
there was no edema in both palpebrae, pupil was
round and isochoric, diameter 3mm/3 mm, light reflex
was positive, sunken eye (-)
Nose : Intact nasal septum, not hiperemic, nasal flare (-),
Ear : There was no ear discharge
Mouth : wet mocous surface, pale (+)

Tonsil : reddish of tonsil, enlargement of tonsil, T2/T2
Figure 8. tonsil of the patient. enlargement of tonsil, T2/T2.

Centor score : Age :1
Exudate :1
Lymph node : 1
Temperature : 1
Cough :1
Total :5
Neck There was enlargement of limphnodes
Thorax Normal shape, simetrical, there was no delayed movement, subcostal
retraction (+), prominent bones (+)
 Heart
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable
Percussion:
Upper right border : ICS II right parasternal line
Lower right border : ICS IV right parasternal line
Upper left border : ICS II left parasternal line

Lower left border : ICS IV left midclavicular line
Auscultation : normal heart sound, murmur (-), gallop (-)
Conclussion : normal
Lung
Anterior Right Left
Inspection Symetrical, minimal Symetrical, minimal

subcostal retraction (+) subcostal retraction (+)
Palpation Normal Normal
Percussion Sonor Sonor
Auscultation Breath sound vesicular, Breath sound vesicular,

ronchi (+) whezzing (-) ronchi (+) whezzing (-)
Posterior Right Left
Inspection Symetrical Symetrical
Palpation Normal Normal
Perkusi Sonor Sonor
Auscultation Breath sound vesicular, Breath sound vesicular,

ronchi (+) whezzing (-) ronchi (+) whezzing (-)
Abdomen Inspection: umbilicus potruded, collateral vein not visible

Ausculation: normal bowel sound
Percussion: tympanic, there was no shifting dullness and undulation
Palpation: slight distended, enlargement of liver and spleen, skin turgor
normal
Extremities Warm acral, capillary refill time 1 second, no edema in pretibia, upper
and lower extremities. Anemic, petechiae, no icteric, no cyanotic.
Multiple lymphadenopathy at armpit and inguinal.
Tuberculosis Fever :1
score Cough :0
Lymph node enlargement :1
Joint inflamation :0
Nutritional status :2
Thorax radiology :0
Tuberculosis contact :0
Mantoux test :0
Total score :5
Urogenital There was axillar hair. Penis lenght 4.5 cms. Circumcision had been
performed. Scrotal was no edema.

Upper Lower
Right Left Right Left
Physiological Normal Normal Normal Normal
Pubertal status
reflex There was no anomaly
Pathological Testicular volume
Negative 25 ml (greater
Negative than 20Negative
Negative ml), scrotum enlarge and dark,
reflex penis length is 6 cm.
Motoric Genitals
5 : Tanner
5 4 5 5
Sensoric Pubic Hair : Normal
Normal Tanner 4 Normal Normal
Testicular : Testicular volume 25 ml
Anal Skin There was no dermatosis nor striae

Neurological Fully alert, GCS 4-5-6. No seizure. Meningeal sign: there was no neck
state stiffness, Brudzinki and kernig sign was negative. There was no cranial
nerve paralysis.
Conclussion: Normal

Table 3. Patient’s laboratory results
Examination Laboratory results Normal range

October 1st 2019 at 19.43 pm (1st day hospitalized)
Hemoglobin 3.1 g/dL 13.4-17.7
Erythrocyte 1.07x106/μL 4.0-5.0
Leucocyte 9310 /µL 4.7-11.3
Hematocrite 53.10% 38-42
Trombocyte 8.000/μl 142-424
MCV/MCH/MCHC 88.80 fL/29 pg/32.6 g/dL 80-93/27-31/32-36
Diff count :
(Eo/Baso/Neu/Lym/ Mono) 0.3%/0.0%/2.5%/95.5%/1.7% 0-4/0-1/51-67/25-33/2-5
AST 11 U/L 0-40
ALT 8 U/L 0-41
Albumin 3.23 g/dl 3.5-5.5
Ureum 41.6 mg/dl 16.6-48.5
Creatinin 0.21 mg/dl <1.2
Procalcitonin 1.42 mg/dl <0.3
Plasma Blood Glucose 110 mg/dl <200

Sodium 125 mmol/L 136-145
Potassium 4.9 mmol/L 3.5-5.0
Chloride 101mmol/L 98-106
Calcium 7.4 mg/dl 7.6-11.0
Phosphor 2.8 mg/dl 2.7-4.5
Blood Gas Analysis
pH 7.36 7.35-7.45
pCO2 26.9 35-45
pO2 34.7 80-100
Bicarbonat 16.5 21-28
Base Excess -9.1 (-3)-(+3)
O2 Saturation 77.3 % >95
Urinalysis
Turbidity Clear
Colour Yellow
pH 6.0 4.5-8.0
Specific gravity 1.010 1.005-1.030
Glucose Negative Negative
Protein Trace Negative
Keton Negative Negative
Bilirubine Negative Negative
Urobilinogen 1.2 Negative
Nitrit Negative Negative
Leukocyte Negative Negative
Blood Negative Negative
Bacteria 197.0x103/ml <23x103/mL

Table 4. Patient’s Sputum Gen Expert Result and Fecal Examination Result
Examination
Laboratory results Normal range
th TH
October 4 2019 at 12.24 pm (4 day hospitalized)
Sputum Gen Expert MTB Not Detected
October 6th 2019 at 12.24 pm (6TH day hospitalized)

Fecal examination
Colour brownish yellow

shape mushy
elemen Negative
epitel + Negative – positif 1
leukosit 0-1 <5
eritrosit Negative Negative
parasit Negative Negative
- Egg worm Negative Negative
- Larva Negative Negative
- trophozoit Negative Negative
- cyste Negative Negative
leftovers Positif Negative
muscle fiber Negative Negative
plant fiber Positif <10
amylum Negative -/+
fat granules Negative -/+
bacteria Negative Steatorhoe > 60
occult blood test (FOBT) Bacteri ++
Negative
Radiology Finding

Figure 9. Thorax antero-posterior.
Conclusion : Pneumonia DD Pneumonic type
Figure 10. Cervical Antero Posterior.

Conclusion : Soft tissue swelling Regio Sinistra Mandibulla

Figure 11. Cervical lateral.
Conclusion : Soft tissue swelling Regio Sinistra Mandibulla
Figure 12. Electrocardiography at October 1st, 2019

Description : Sinus Rhytm, Heart rate 125x/minutes, Axis P: 30-60 O, QRS: 0-30O, T: 30-
60O, Normo axis without strain, R/S ratio at V1 3(10)/2(22) and R/S ratio at V6
12(23)/3(4), PR interval: 0,08 sec, QRS interval: V1 0.04 sec V6 0.04 sec, RR interval:
0.36 sec. Conclusion: sinus rhythm, normal cardiac axis, RVH (-), LVH (-)

Figure 13. Echocardiography, 2019
Conclusion : Mild TR, Pericard Effusion without colaps chamber sign, suggestion:
echocardiography evaluation 6 months
Table 5. Pathology Anatomy Examination Result (FNAB) 27th July 2019

Localization Neck D/S
Result The swelling are multiple, 1-2 cms diameter, mobile,
chewy. We get 2 slides of diff quick.
Microscopic examination the smear consists of solid distribution of lymphocytes
cells, monotone nucleus, some have atypic nucleus, with
little cytoplasm.
Conclusion Left Neck FNAB : Chronic lymphadenitis with atypical
cells. If the clinical condition is suspicious and possible,
please do open biopsy for certain diagnosis.
Table 6. Bone Marrow Examination 3rd September 2019

Examination Result
Hemoglobin 7.5 g/dL
Red Blood Cells 2.58.1012 / L
Hematocrit 21.7%
MCV/MCH 84.1 fL/29.1 pg
RDW-CV 18.6%
Reticulocyte 1.66%
White Blood Cells 18.89.109 / L
Plt 19.109 / L
Diff. Count -/-/-/4/20/-
(Eo/Ba/St/Seg/Ly/Mo) Normoblast : 1/100 leucocytes
Lymphoblast : 76%
Peripheral Blood Smear

Eritrocyte normochrome anisopoikilocytosis, microcytic (+),
macroovalocyte (+), polychromation (+), normoblast (+)
Leucocytes Impression of increasing number, lymphoblast (+)
Thrombocytes Impression of decreasing number
Bone Marrow Cellularity : Hypercelullar

M:E Ratio : 1:1
Erytropoiesis : decreasing activity
Granulopoiesis : decreasing activity
Megacaryopoiesis : decreasing activity
Reserved Fe : cannot be evaluated
Others : There is lymphoblast proliferation 76%, with
morphology : heterogen size, round-oval nucleus, cleft (+),
seen nucleolus, variated basophilic cytoplasm.
Conclusion Acute Lymphoblastic Leukemia (ALL L2)
Summary of basic data

A 13 year-old boy was brought to the emergency room of general hospital
on October 1st, 2019 with chief complaint pallor. Patient looked pallor in the last
two months and getting worse in a week before admission. Pallor was seen on
both of palms and feet. There was no hystory of active bleeding but he had
reddish spot in both of feet and hands since two weeks before admission..
Patient also complained shortness of breath a week before admission. Shortness
of breath was worsened a day before admission. Patient also complained with
cough since one week before admission. His father is a smoker. Patient school at
pesantren and he has nine person roommate.
Patient suffered from recurrent fever with the highest temperature at 38 o C
since 2 months ago. Fever temporarily relieved with oral paracetamol. The last
three days before admission the temperature raising until 39 o C accompanied
with sore throat.
Patient complained of a mass in the left neck since 3 months prior to
admission. Mass consistency was hard, well defined, fixed, and no pain. Mass
has gotten bigger since two months before admission. Mass became multiple and
spread to the right neck, armpits, and inguinal since one month before admission.

Patient suffered from diarrhea since one week before admission. The
frequency was seven times a day with loose consistency, there was no mucus
and blood. Patient had decrease of appetite in the last three months, and only ate
porridge. He also suffered from sore throat since three days before admission.
His mother said that he became thinner since three months before admission.
There was no history of vomiting.
Anthropometric evaluation of the patient showed weight was 35 kgs (P3 to
P10), height was 155 cms (P25-P50), head circumference was 52,5 cms (-2 SD
to mean), arm circumference was 18 cms (<P5) and ideal body weight was 45
kgs with percent ideal body weight was 77%. These results showed
anthropometric status of this patient was malnutrition (marasmic type
malnutrition).
At the time patient came to emergency ward (October 1 st, 2019), patient
looked moderately ill characterized with pale, fever, and dyspneu. Hemodynamic
evaluation showed pulse rate was 91 times/minutes, blood pressure was 100/70
mmHg, respiratory rate was 30 times/minutes, axillary temperature was 39oC and
oxygen saturation was 99% with nasal canul. The GCS was E4V5M6, isochoric
pupil with diameter 3mm/3mm, good light and cornea reflex. Tonsil was
hyperemic and enlarged. Palpation from the abdomen showed slightly distended
with liver and spleen enlargement.
Laboratory test result on emergency ward (October 1st, 2019) showed Hb
3.1 g/dL, leucocyte 9.310/mm3, platelet 8.000/mm3, MCV 88.8 Fl, MCH 29 Pg,
MCHC 3.9 g/DI, neutrophil count 2.5%, lymphocyte 95.5%, monocyte 1.7%, ANC
232.75, AST 11 U/L, ALT 8 U/L, Albumin 3.23 g/dL, blood glucose 110 mg/dL,
ureum 41.6, creatinin 0.21 mg/dL, natrium 125 Mmol/L, potassium 4.9 Mmol/L,
chloride 101 Mmol/L, calcium 7.4 Mmol/L, phospor 2.8 Mmol/L. Urinalysis
showed protein trace, glucose negative, leucocyte negative, nitrit negative,
hematuria negative, with bacteriuria was 197,000/mL. Chest radiography result
was showed normal cardio thorax ratio with infiltrat in right paracardial suggested
a pneumonia dd pneumonic type metastasis. Electrocardiography evaluation with
in normal limit.
Problem list
 Severe Anemia

 Acute Lymphoblastic Leukemia-L 2
 Respiratory distress
 Trombocytopenia
 Severe Neutropenia
 Febrile Neutropenia
 Marasmic type and malnourishment
 Acuter Diarrhea without dehydration
 Acute tonsilitis
Working diagnosis
a. Acute Lymphoblastic Leukemia L 2 (C91.00)
b. Severe Neutropenia (D70.3)
c. Febrile Neutropenia (D70.9)
d. Severe Anemia (D61.9)
e. Pneumonia (J18.9)
f. Marasmic Type and Malnourishment (E41)
g. Acute Diarrhea Without Dehydration (R19.7)
h. Acute Tonsilitis (J03.90)
Planing management
a. Planing diagnosis
 Urine culture, blood culture, fecal culture, sputum culture
 Screening tuberculosis
b. Planing Therapy
 Nasal canule 2 lpm oxygen
 Intravenous Ceftriaxon 2x 1 grams (100 mg/kg/day)
 Transfussion PRC I 200 cc (interval 24 hours)  Transfussion PRC II 300
cc (interval 24 hours)  Transfussion PRC III 350 cc (interval 24 hours)
 Transfussion PRC IV 150 cc (interval 24 hours)
 Transfussion TC 350 cc, three times interval 24 hours
 oral route : Vitamin BC 1x1 tablet
Vitamin C 1x100 mg

Vitamin E 1x100 IU
Folic Acid 1x1 mg
Zinc 1x20 mg
c. Planing Nutritional Therapy

Basic nutritional needs of children according to recommended daily
allowance.
Fluid requirement : 1800 cc/day
Calory Requirement: RDA x BBI x 50% : 1237 kkal/day
Protein Requirement: RDA x BBI x 50% : 22.5 gr/day
Route of nutrition oral route
Nutrition: F75 8x150 cc (1200 cc, 900 kkal)
d. Planing of Monitoring
Vital sign, body weight, urine production, fluid balance.
e. Planing of Education
 Explain to the family about the illness suffered by the child, the cause,
the course of the disease, care, prognosis, complications, prevention of
complications
 Explain about examination for diagnosis and long term monitoring
 Explain the effect of disease on child growth and development
 Motivate parent and family to perform chemotherapy
 Food arrangement
 Explanation about complication of disease and work up complication.

Monitoring When Case Accepted

Thursday, October 3rd, 2019 (observation day-1, hospitalization day-3)
S Pale (+), Fever (+),dyspneu (+), vomiting (-), Bleeding sign (-), Diarrhea (+)
O General appearance: moderately ill, paleness and compos mentis. (BW: 35 kg)
Vital signs: pulse rate 96 times per minute, respiratory rate 24 times per minute, body temperature 37.9°C, oxygen saturation is
97%, blood pressure 100/60 mmHg. Conjunctival anemis +/+, scleral icteric (-).
Achieved 67% fluid requirement; calories 72%; protein 53%.
A - ALL-L2 (C91.01)
- Febrile Netropenia (D70.9)
- Severe Netropenia (D70.9)
- Severe Anemia (D64.9)
- Marasmic Type Malnourishment Transition Phase (E41)
- Pneumonia (J18.9)
- Acute Diarrhea without Dehydration (R19.7)
- Acute tonsillitis (J03.90)
P Planing diagnosis: Consultation to Cardiology Division, Work Up TB (Mantoux test, sputum cultural, Gene expert),
Gastrohepatology Division, Pediatric Growth and Development Division.
 Gastrohepatology Consultation: Acute Diarhea without Dehydration. Suggestion: Peroral Zinc 1x20 mg, Peroral Resomal 10
cc/kgBW (each diarrhea)

 Pediatric Growth and Developmental Consultation: decrease of quality of life. Suggestion: consulation to psychiatric division,
developmental and quality of life monitoring, side effect chemoteraphy regimen monitoring.
Planing therapy:
Fluid requirement : Holliday Segar = 1800 cc/day
Calorie requirement : RDAx IBWx 75% = 1856,2 kcal/day
Protein requirement : RDAx IBWx 75% = 33,75 gr/day
- Oxygen nasal canule 2 litre per minutes

- Intravenous Ceftriaxone 2x1 g (100mg/kgBW/day) (2)
- PRC Transfussion 200 cc (+)  300 cc (+)  350 cc  150 cc (each 24 hours)
- TC Transfussion 350 cc (3 times) each 24 hours
- Peroral Vitamin BC 1x1 tab
- Peroral Vitamin C 1x100 mg
- Peroral Vitamin E 1x100 IU
- Peroral Folic acid 1x1 mg
- Peroral Zinc 1x20 mg
- Diet: F100 8x 150 cc (1200 cc, 1200 Kcal, 36 gram)
- High Calories High Protein Diet 3x ½ portion (300 cc, 800 kcal, 35 gram)
Fluid fulfilled target : 1500 cc (83,3 %)

Calorie fulfilled target : 2000 kcal (107,7%)
Protein fulfilled target : 71 grams (210%)
Planning monitoring : General appearance, vital signs: heart rate, respiratory rate, axillary temperature, blood glucose levels,
urine production and fluid balance, respiratory distress, body weight daily, tolerance, Mid-upper arm circumference and body
length per week.
Fluid balance/ 24 hours: deficit 1,1 cc/kgs ~ deficit 0,2% total body water
Urine production: 1.8 cc/kgs/hour

Friday, October 4th, 2019 (observation day-2, hospitalization day-4)
S Pale (+), Fever (-), vomiting (-), dyspneu (+), dhiarrhea (+)
Vital signs: pulse rate 90 times per minute, respiratory rate 24 times per minute, body temperature 37°C, oxygen saturation is
97%, blood pressure 105/60mmHg. Conjunctival anemis +/+, Scleral icteric (-).
Achieved 83% fluid requirement; calories 107%; protein 210%.
A - ALL-L2 (C91.01)
- Marasmic Type Malnourishment Rehabilitation Phase (E41)
- Pneumonia (J18.9)
P Planing diagnosis: Sputum culture, Consultation to Cardiology Division

 Cardiology Consultation: Mild TR, Pericard Effusion without colaps chamber sign. Suggestion: echocardiography evaluation 6
months
Planing therapy:

Calorie requirement : RDAx IBWx 100% = 2475 kcal/day
Protein requirement : RDAx IBWx 100% = 45 gr/day
- Intravenous Ceftriaxone 2x175 mg (100mg/kgBW/day) (3)
- PRC Transfussion 200 cc (+)  300 cc (+)  350 cc (+)  150 cc (each 24 hours)
- High Calories High Protein Diet 3x 1 portion (600 cc, 1600 kcal, 70 gram)
- Mineral Water up to 500 cc/ day
Fluid fulfilled target : 2000 cc (111 %)
Calorie fulfilled target : 2000 kcal (80,8%)
Protein fulfilled target : 71 grams (157,7%)

length per week
Fluid balance/ 24 hours: deficit 1,51 cc/kgs ~ deficit 0,25% total body water

Saturday, October 5th, 2019 (observation day-3, hospitalization day-5)
S Pale (+), Fever (-), vomiting (-), dyspneu (+), Diarrhea (+)
Vital signs: pulse rate 96 times per minute, respiratory rate 24 times per minute, body temperature 36,8°C, oxygen saturation is
Achieved 111% fluid requirement; calories 80,8%; protein 157,7%.
A - ALL-L2 (C91.01)
- Pneumonia (J18.9)
P Planing diagnosis: Blood culture, Fecal analysis, Culture Faecal
Planing therapy:

- TC Transfussion 350 cc (3 times) each 24 hours (I)
- Peroral Resomal 10 cc/kgBW (if diarrhea)

Calorie fulfilled target : 2800 kcal (113%)
length per week
Fluid balance/ 24 hours: deficit 6 cc/kgs ~ deficit 1 % total body water


Sunday, October 6th, 2019 (observation day-4, hospitalization day-6)
S Pale (+), Fever (-), vomiting (-), dyspneu (+), Diarrhea (-)
Achieved 127,7% fluid requirement; calories 113%; protein 235%.
A - ALL-L2 (C91.01)
- Pneumonia (J18.9)
P Planing therapy:


- TC Transfussion 350 cc (3 times) each 24 hours (II)
length per week
Fluid balance/ 24 hours: deficit 10 cc/kgs ~ deficit 1,8% total body water

Monday, October 7th, 2019 (observation day-5, hospitalization day-7)
A - ALL-L2 (C91.01)
- Pneumonia (J18.9)
P Planing diagnostic: Mantoux test, complete blood count after transfussion, consulation to psychiatric division
 Psychiatric Consultation: Adjustment disorder. Suggestion: Psychotherapy by a psychologist in office hours. Patients we
will follow during treatment.
Planing therapy:


- TC Transfussion 350 cc (3 times) each 24 hours (III)


length per week
Fluid balance/ 24 hours: deficit 15 cc/kgs ~ deficit 2 % total body water

Tuesday, October 8th, 2019 (observation day-6, hospitalization day-8)
A - ALL-L2 (C91.01)
- Pneumonia (J18.9)
P Planing diagnostic: Mantoux test, complete blood count after transfussion

Planing therapy:

- PRC Transfussion 300 cc
- Peroral KSR 1x200 mg


length per week
Fluid balance/ 24 hours: 12 cc/kgs ~ deficit 1.8% total body water

Wednesday, October 9th, 2019 (observation day-7, hospitalization day-9)
A - ALL-L2 (C91.01)
- Pneumonia (J18.9)
P Planing diagnostic: Mantoux test, complete blood count after transfusion

Planing therapy:

- PRC Transfussion 300 cc
- Peroral KSR 1x200 mg


length per week
Fluid balance/ 24 hours: deficit 10 cc/kgs ~ deficit 1.3% total body water
Urine production: 2 cc/kgs/hour
Monitoring when case accepted

General appearance: moderately ill, General appearance: moderately ill, General appearance: moderately ill, General appearance: moderately ill, General appearance: moderately ill, General appearance: moderately ill, General appearance: moderately ill,
paleness and compos mentis. paleness and compos mentis. paleness and compos mentis. paleness and compos mentis. paleness and compos mentis. paleness and compos mentis. paleness and compos mentis.
Vital signs: pulse rate 96 times per Vital signs: pulse rate 90 times per Vital signs: pulse rate 96 times per Vital signs: pulse rate 84 times per
Vital signs: pulse rate 88 times per Vital signs: pulse rate 88 times per Vital signs: pulse rate 80 times per
minute, respiratory rate 24 times per minute, respiratory rate 22 times per
minute, body temperature 37.9°C,
minute, respiratory rate 24 times per minute, respiratory rate 24 times per minute, respiratory rate 20 times per minute, respiratory rate 20 times per minute, respiratory rate 22 times per
minute, body temperature 37°C, minute, body temperature 36,8°C, minute, body temperature 37°C, oxygen minute, body temperature 37°C, minute, body temperature 36,7°C, minute, body temperature 36,9°C,
oxygen saturation is 97%, blood
pressure 100/60 mmHg. Conjunctival oxygen saturation is 97%, blood oxygen saturation is 97%, blood saturation is 99%, blood pressure 90/60 oxygen saturation is 99%, blood oxygen saturation is 99%, blood oxygen saturation is 99%, blood
anemis +/+,.Scleral icteric (-). pressure 90/60mmHg. Conjunctival pressure 95/65 mmHg. Conjunctival mmHg. Conjunctival anemis +/+,.Scleral pressure 100/60 mmHg. Conjunctival pressure 90/60 mmHg. Conjunctival pressure 90/60 mmHg. Conjunctival
Achieved 67% fluid requirement; anemis +/+, Scleral icteric (-). anemis +/+,.Scleral icteric (-). icteric (-). anemis +/+,.Scleral icteric (-). anemis +/+,.Scleral icteric (-). anemis +/+,.Scleral icteric (-).
calories 72%; protein 53%. Achieved 83% fluid requirement; Achieved 111% fluid requirement; Achieved 127,7% fluid requirement; Achieved 127,7% fluid requirement; Achieved 127,7% fluid requirement; Achieved 127,7% fluid requirement;
Fluid balance/ 24 hours: deficit 1,1 calories 107%; protein 210%. calories 80,8%; protein 157,7%. calories 113%; protein 235%. calories 113%; protein 235%. calories 113%; protein 235%. calories 113%; protein 235%.
cc/kgs ~ deficit 0,2% total body water Fluid balance/ 24 hours: deficit 1,51 Fluid balance/ 24 hours: deficit 6 cc/kgs Fluid balance/ 24 hours: deficit 10 Fluid balance/ 24 hours: deficit 15 Fluid balance/ 24 hours: deficit 12 Fluid balance/ 24 hours: deficit 10
Urine production: 1,8 cc/kgs/hours cc/kgs ~ deficit 0,25% total body ~ deficit 1 % total body water cc/kgs ~ deficit 1,8% total body water cc/kgs ~ deficit 2 % total body water cc/kgs ~ deficit 1.8% total body water cc/kgs ~ deficit 1.3% total body water
Gastrohepatology Consultation: Acute Urine production: 2 cc/kgs/hour
water Urine production: 1.9 cc/kgs/hour Urine production: 2,5 cc/kgs/hour Urine production: 2,2 cc/kgs/hour Urine production: 2,4 cc/kgs/hour
Diarhea without Dehydration,
Suggestion: Peroral Zinc 1x20 mg, Urine production: 2,19 cc/kgs/hour
Peroral Resomal 10 cc/kgBW (each Cardiology Consultation: Mild TR,
diarrhea) Pericard Effusion without colaps
Pediatric Growth and Developmental chamber sign, suggestion:
Longitudinal Case-Local Evaluation, Malang October 10th, 2019
Consultation: decrease of quality of echocardiography evaluation 6 46
life, suggestion: consulation to months
psychiatric division, developmental
and quality of life monitoring, side
effect chemoteraphy regimen
monitoring.
Acute Lymphoblastic Leukemia L
2 (C91.00), Severe Neutropenia ALL-L2 (C91.01), Severe Anemia (D64.9), Marasmic Type Malnourishment (E41),
(D70.3), Febrile Neutropenia Febrile Netropenia (D70.9), Severe Netropenia (D70.9)
(D70.9), Severe Anemia (D61.9) Pneumonia (J18.9), Acute Diarrhea without Dehydration (R19.7), Acute Tonsilitis (J03.90)
Pneumonia (J18.9), Marasmic
Type and Malnourishment (E41)
Acute Diarrhea Without
Dehydration (R19.7), Acute
Tonsilitis (J03.90)
October, 3rd 2019 October, 5th 2019 October, 6th 2019 October, 7th 2019 October, 8th 2019 October, 9h 2019
October, 4th 2019
Oxygen nasal canule 2 litre per minutes Oxygen nasal canule 2 litre per Oxygen nasal canule 2 litre per Oxygen nasal canule 2 litre per minutes Oxygen nasal canule 2 litre per minutes Oxygen nasal canule 2 litre per minutes Oxygen nasal canule 2 litre per minutes
Intravenous Ceftriaxone 2x1 g minutes minutes Intravenous Ceftriaxone 2x175 mg Intravenous Ceftriaxone 2x175 mg Intravenous Ceftriaxone 2x175 mg Intravenous Ceftriaxone 2x175 mg
(100mg/kgBW/day) (2) Intravenous Ceftriaxone 2x175 mg Intravenous Ceftriaxone 2x175 mg (100mg/kgBW/day) (5) (100mg/kgBW/day) (6) (100mg/kgBW/day) (7) (100mg/kgBW/day) (8)
PRC Transfussion 200 cc (+) 300 cc (100mg/kgBW/day) (3) (100mg/kgBW/day) (4) TC Transfussion 350 cc (3 times) each TC Transfussion 350 cc (3 times) each 24 PRC Transfussion 300 cc PRC Transfussion 300 cc
(+) 350 cc 150 cc (each 24 hours) PRC Transfussion 200 cc (+) 300 cc TC Transfussion 350 cc (3 times) each 24 hours (II) hours (III) TC Transfussion 350 cc (3 times) each TC Transfussion 350 cc (3 times) each
TC Transfussion 350 cc (3 times) each (+) 350 cc (+) 150 cc (each 24 hours) 24 hours (I) Peroral Vitamin BC 1x1 tab Peroral Vitamin BC 1x1 tab 24 hours 24 hours
24 hours TC Transfussion 350 cc (3 times) each Peroral Vitamin BC 1x1 tab Peroral Vitamin C 1x100 mg Peroral Vitamin C 1x100 mg Peroral Vitamin BC 1x1 tab Peroral Vitamin BC 1x1 tab
Peroral Vitamin BC 1x1 tab 24 hours Peroral Vitamin C 1x100 mg Peroral Vitamin E 1x100 IU Peroral Vitamin E 1x100 IU Peroral Vitamin C 1x100 mg Peroral Vitamin C 1x100 mg
Peroral Vitamin C 1x100 mg Peroral Vitamin BC 1x1 tab Peroral Vitamin E 1x100 IU Peroral Folic acid 1x1 mg Peroral Folic acid 1x1 mg Peroral Vitamin E 1x100 IU Peroral Vitamin E 1x100 IU
Peroral Vitamin E 1x100 IU Peroral Vitamin C 1x100 mg Peroral Folic acid 1x1 mg Peroral Zinc 1x20 mg Peroral Zinc 1x20 mg Peroral Folic acid 1x1 mg Peroral Folic acid 1x1 mg
Peroral Folic acid 1x1 mg Peroral Vitamin E 1x100 IU Peroral Zinc 1x20 mg Peroral Resomal 10 cc/kgBW (if Peroral Resomal 10 cc/kgBW (if diarrhea) Peroral KSR 1x200 mg Peroral KSR 1x200 mg
Peroral Zinc 1x20 mg Peroral Folic acid 1x1 mg Peroral Resomal 10 cc/kgBW (if diarrhea) Diet: F100 8x 150 cc (1200 cc, 1200 Kcal, Peroral Zinc 1x20 mg Peroral Zinc 1x20 mg
Diet: F100 8x 150 cc (1200 cc, 1200 Peroral Zinc 1x20 mg diarrhea) Diet: F100 8x 150 cc (1200 cc, 1200 36 gram) Peroral Resomal 10 cc/kgBW (if Peroral Resomal 10 cc/kgBW (if
Kcal, 36 gram) Diet: F100 8x 150 cc (1200 cc, 1200 Diet: F100 8x 150 cc (1200 cc, 1200 Kcal, 36 gram) High Calories High Protein Diet 3x 1 diarrhea) diarrhea)
High Calories High Protein Diet 3x ½ Kcal, 36 gram) Kcal, 36 gram) High Calories High Protein Diet 3x 1 portion (600 cc, 1600 kcal, 70 gram) Diet: F100 8x 150 cc (1200 cc, 1200 Diet: F100 8x 150 cc (1200 cc, 1200
portion (300 cc, 800 kcal, 35 gram) High Calories High Protein Diet 3x 1 High Calories High Protein Diet 3x 1 portion (600 cc, 1600 kcal, 70 gram) Mineral Water up to 500 cc/ day Kcal, 36 gram) Kcal, 36 gram)
portion (600 cc, 1600 kcal, 70 gram) portion (600 cc, 1600 kcal, 70 gram) Mineral Water up to 500 cc/ day High Calories High Protein Diet 3x 1 High Calories High Protein Diet 3x 1
Mineral Water up to 500 cc/ day Mineral Water up to 500 cc/ day portion (600 cc, 1600 kcal, 70 gram) portion (600 cc, 1600 kcal, 70 gram)
Mineral Water up to 500 cc/ day Mineral Water up to 500 cc/ day

PROGNOSIS
Prognosis ad vitam : dubia ad malam
Prognosis ad fungsionam : dubia ad malam
Prognosis ad sanasionam : dubia ad malam

CASE ANALYSIS
A 13 year-old boy was brought to the emergency room of general hospital

on October 1st, 2019 with chief complaint pallor. Patient suffered from pallor since
a week before admission. Patient was diagnosed with acute lymphoblastic
leukemia 2, severe anemia, severe neutropenia, febrile neutropenia, marasmic
type and malnourishment, pneumonia, acute diarrhea without dehydration and
acute tonsilitis.
1. Acute lymphoblastic leukemia (ALL)
Acute lymphoblastic leukemia (ALL) is a cancer of the lymphoid

line of blood cells characterized by the development of large numbers
of immature lymphocytes. Symptoms may include feeling tired, pale skin
color, fever, easy bleeding or bruising, enlarged lymph nodes, or bone pain. As
an acute leukemia, ALL progresses rapidly and is typically fatal within weeks or
months if left untreated (Marino, 2013). In most cases, the cause is
unknown. Genetic risk factors may include Down syndrome, Li-Fraumeni
syndrome, or neurofibromatosis type 1. Environmental risk factors may include
significant radiation exposure or prior chemotherapy (Hunger, 2015).
Evidence regarding electromagnetic fields or pesticides is unclear. Some

hypothesize that an abnormal immune response to a common infection may be a
trigger. The underlying mechanism involves multiple genetic mutations that
results in rapid cell division. The excessive immature lymphocytes in the bone
marrow interfere with the production of new red blood cells, white blood cells,
and platelets. Diagnosis is typically based on blood tests and bone marrow
examination (Inaba, 2013). This is then followed by further chemotherapy
typically over a number of years. Additional treatments may include intrathecal
chemotherapy or radiation therapy if spread to the brain has occurred. Stem cell
transplantation may be used if the disease recurs following standard treatment
(Hunger, 2015).
Diagnosing ALL begins with a through medical history, physical

examination, complete blood count, and blood smears. While many symptoms of
ALL can be found in common illnesses, persistent or unexplained symptoms
raise suspicion of cancer. Because many features on the medical history and
exam are not specific to ALL, further testing is often needed. A large number of

white blood cells and lymphoblasts in the circulating blood can be suspicious for
ALL because they indicate a rapid production of lymphoid cells in the marrow.
The higher these numbers typically points to a worse prognosis. While white
blood cell counts at initial presentation can vary significantly, circulating
lymphoblast cells are seen on peripheral blood smears in the majority of cases
(Baljevic, et al., 2016).
A bone marrow biopsy provides conclusive proof of ALL, typically with

>20% of all cells being leukemic lymphoblasts. Laboratory tests that might show
abnormalities include blood count, kidney function, electrolyte, and liver enzyme
tests. Medical imaging (such as ultrasound or CT scanning) can find invasion of
other organs commonly the lung, liver, spleen, lymph nodes, brain, kidneys, and
reproductive organs. This patient perform ALL-L2 from bone marrow biopsy.
Historically, prior to 2008, ALL was classified morphologically using the French-
American-British (FAB) system that heavily relied on morphological assessment.
The FAB system takes into account information on
size, cytoplasm, nucleoli, basophilia (Ladines-Castro, et al., 2015).
Figure 16. French-American-British (FAB) classification of acute

lymphoblastic leukaemia.
ALL-L1 85% cases in children, ALL-L2 18% cases in children and ALL-L3 is rare case.
(Ladines-Castro, et al., 2015)

In 2008, the World Health Organization classification of acute
lymphoblastic leukemia was developed in an attempt to create a classification
system that was more clinically relevant and could produce meaningful
prognostic and treatment decisions. This system recognized differences in
genetic, immunophenotype, molecular, and morphological features found
through cytogenetic and molecular diagnostics tests. This subtyping helps
determine the prognosis and the most appropriate treatment for each specific
case of ALL (Arber, et al., 2016).
The aim of treatment is to induce a lasting remission, defined as the

absence of detectable cancer cells in the body (usually less than 5% blast cells in
the bone marrow). Over the past several decades, there have been strides to
increase the efficacy of treatment regimens, resulting in increased survival rates.
Possible treatments for acute leukemia include chemotherapy, steroids, radiation
therapy, intensive combined treatments (including bone marrow or stem
cell transplants), and/or growth factors (Arber, et al., 2016)
Chemotherapy is the initial treatment of choice, and most people with ALL
receive a combination of medications. There are no surgical options because of
the body-wide distribution of the malignant cells. In general, cytotoxic
chemotherapy for ALL combines multiple antileukemic drugs tailored to each
person. Chemotherapy for ALL consists of three phases: remission induction,
intensification, and maintenance therapy. The criteria for high risk in ALL
chemotherapy are less than age one or older than ten years of age, more than
50,000 white blood cells/mm3 of blood when they are diagnosed, more than 5
leukemic cells in the CSF (CNS 3), leukemia cells with chromosome changes that
are more difficult to treat, testicular involvement, steroids given before diagnosis
of leukemia. (Hunger, et al., 2015).

Table 6. Chemotherapy of acute lymphoblastic leukemia
Phase Description Agents
Aim to:
 Rapidly kill most tumor cells
 Reduce leukemic blasts in the bone Combination of:
marrow to <5% and eliminate tumor  Steroids-prednisolone or dexamethaso
cells from blood ne
 Induce absence of other signs and
 vincristine
symptoms of the disease.
 asparaginase (better tolerance in
Must monitor closely for tumor lysis
people in pediatric care)
syndrome after initiating therapy
Monitoring initial response to treatment is  daunorubicin (used in Adult ALL)
Remission induction Central nervous system prophylaxis can be
important as failure to show clearance of
blood or bone marrow blasts within the first 2 achieved via:[45]
weeks of therapy has been associated with - cranio-spinal irradiation
higher risk of relapse - cytarabine + methotrexate
1. May need to intensify treatment if - or liposomal cytarabine
remission is not induced In Philadelphia chromosome-positive ALL,
Start CNS prophylaxis and the intensity of initial induction treatment may
administer intrathecal be less than has been traditionally given. [46][47]
chemotherapy via Ommaya reservoir or
multiple lumbar punctures
Typical protocols use the following given as
blocks (varies from 1-3 blocks depending on
person's risk category) in different multi-drug
combinations:
- vincristine
- cyclophosphamide
- cytarabine
Consolidation/intens Use high doses of chemotherapy to further
- daunorubicin
ification reduce tumor burden
- etoposide
- thioguanine
- mercaptopurine
Central nervous system relapse is treated
with intrathecal administration
of hydrocortisone, methotrexate, and
cytarabine.
Kill any residual cell that was not killed by
remission induction and intensification
regimens
- Can sometimes start immediately after
Typical protocol would include:
remission induction and be interrupted
- daily oral mercaptopurine
Maintenance therapy by bursts of consolidation/intensification
- weekly oral methotrexate
therapy
- monthly 5-day course of intravenous
- Although such residual cells are few,
vincristine and oral corticosteroids
they will cause relapse if not eradicated
- Length of maintenance therapy is 3
years for boys, 2 years for girls and
adults
There are three phases of chemoterapy for ALL. Every step had different aim to
depressed the cell cancer.
(Hunger, et al., 2015)

Besides chemotherapy, ALL can be managed by using radiotherapy,
biological therapy and immunotherapy. Planning treatment for this patient is
chemotherapy for acute lymphoblastic leukemia (high risk) national protocol
2018. This patient had chemotherapy high risk because of he was diagnosed at
13 years old. The chemotherapy will begin if the patient has fulfill the criteria of
chemotherapy. Patient and his parents have prepared mentally about the side
effect of chemotherapy.
2. Anemia
Anemia is a condition in which the number of red blood cells (and

consequently their oxygen-carrying capacity) is insufficient to meet the body’s
physiologic needs. Specific physiologic needs vary with a person’s age, gender,
residential elevation above sea level (altitude), smoking behaviour, and different
stages of pregnancy. Iron deficiency is thought to be the most common cause of
anemia globally, but other nutritional deficiencies (including folate, vitamin B12
and vitamin A), acute and chronic inflammation, parasitic infections, and inherited
or acquired disorders that affect haemoglobin synthesis, red blood cell production
or red blood cell survival, can all cause anemia (World Health Organization,
2007).
Table 7. Haemoglobin levels to diagnose anemia at see level (g/l)
(World Health Organization, 2007)

Anemia is common in patients with newly diagnosed childhood acute
lymphoblastic leukemia (ALL). The pathomechanism of anemia in childhood ALL
is not completely understood. Anemia in children with cancer is associated with
decreased erythropoietic activity but not with inadequate erythropoietin
production, leading to the assumption that anemia in patients with leukemia
mainly results from suppression of normal hematopoiesis in the bone marrow by
infiltrating blasts. To further understand the pathophysiology of anemia in
childhood ALL, it is important to consider the heterogeneity of diseases in these
patients, including immunological subgroups (precursor B-cell ALL versus T-cell
leukemia) and cytogenetic subgroups (e.g. TELAML1, E2A-PBX1, BCR-ABL,
hyperdiploid karyotype with >50 chromosomes, and MLL gene rearrangements)
(Teuffel, et al., 2018).
Table 8. A pathogenesis-based classification of etiologies of anemia in patients

with malignancies.
.
(Teuffel, et al., 2018)

Red blood cells (RBC) transfusions are almost universally successful in
raising Hb levels and the oxygen transport capacity of the blood. Therefore, they
represent a fast and effective therapeutic intervention useful to ameliorate rapidly
the patient’s symptoms, e.g., breathlessness, and improve health-related QL.
Prior to rHuEPO being available, blood transfusions were the only therapeutic
option for the improvement of symptomatic anemia in cancer patients. The major
benefit, not provided by any alternative therapy for anemia, is the fast Hb and Hct
value rise. Red blood cell transfusions are particularly useful in case of severe
symptomatic anemia or anemia compromising patient life (Hb and Hct value rise.
RBC transfusions are particularly useful in case of severe symptomatic anemia or
anemia compromising patient life (Hb <7-8 g/dl). The need for blood transfusion
depends other factor, vital signs and severe tissue hyperoxygenation
(Chiabrando, et al., 2014).

Figure 17. An algorithmic approach to anemia in a cancer patient. [Note:
The black boxes highlight key investigations often vital to the differential
diagnosis]
The pathomechanism of anemia in childhood ALL is not completely understood.
(Macciò, et al., 2012)
In this patient we found that this patient suffered from severe anemia
(Hb.3,1 g/dl) with predominant blast cell followed by severe thrombocytopenia.
So we can conclude that anemia for this patient caused by malignancy in bone
marrow that suitable for the manifestation of acute leukemia. Treatment for this
patient is several times of transfussion.

3. Febrile Neutropenia
Fever is defined as a one-time measurement of body temperature over
38.3 ° C or permanent body temperature> 38 ° C for more than an hour
(Lehrnbecher, et al., 2012). The pathophysiology of fever is caused by the
presence of exogenous or endogenous pyrogens that stimulate the formation of
prostaglandin E2, where prostaglandin E2 will stimulate an increase in the
thermostat set point in the hypothalamus. Fever can be caused by infections,
malignancies or autoimmune processes. A history of infection and fever
characteristics can help to find the cause (Soegijanto, 2010). To distinguish fever
in malignancy caused by the process of infection or because the malignancy itself
can be distinguished from several factors as can be seen in the following Table 9
(Rezeki, 2011).
Table 9. Differentiation between fever caused by infection and fever caused by

malignancy
Parameters Fever caused by Fever caused by malignancy

Infection
Fever > 39,5 °C 39 – 39.5 °C

Rigor Yes No
Relative Bradicardia Yes No
General Condition Toxic Non Toxic
Netropenia Yes No
Response to antipiretic Yes No
Leucocyte, CRP, LED Increase Normal/slightly increase
(Rezeki, 2011)
The conditions of blood disorders, granulocyte disorders characterized by

neutrophil deficiencies, a type of white blood cells that protect the body against
bacterial and fungal infections. Granulocytes are a category of white blood cells
produced by bone marrow. Neutropenia refers to neutrophil deficiency alone,
whereas agranulocytosis is when bone marrow fails to make enough
granulocytes in general (Nihal, et al., 2016).

Table 10. Score Index MASCC to identify low risk patient with febrile
neutropenia.
Characteristic Score
Symptoms
No symtomps/mild symptoms 5
Moderate symptoms 3
No hypotension 5
No chronic obstructive lung disease 4
Solid tumor or no previous fungal infection 4
No dehydration 3
Onset of fever 3
Age < 60 years 2
Note: Range of score 0-26; score ≥ 21 indicated patient has low risk develop to medical
complication and mortality. MASCC : Multinational Association of Supportive Care in
Cancer. (Gary and Kenneth, 2017)
Neutropenia is defined as an absolute neutrophil count (ANC) <500 cells

/ mm3 or ANC is expected to decrease to <500 cells / mm3 during the next 48
hours (Lehrnbecher, et al., 2012). Absolute neutrophil count can be calculated by
multiplying the percentage of stab neutrophils and segments by the total number
of leukocytes. Neutropenia is classified into mild neutropenia (ANC 1000-1500 /
µL), moderate neutropenia when ANC is between 500-1000 / µL, and severe
neutropenia when ANC <500 / µL (Seals & Halterman, 2008).
Febrile Neutropenia (FN) is defined as a condition with axillary
temperature> 38ºC with an absolute neutrophil count (ANC) <500 / mm3 or which
has an ANC between 500 and 1,000 / mm3 which is expected to decrease below
500 / mm3 in 24-48 hours. Febrile neutropenia is an emergency in the field of
hemato oncology, where earlier management will significantly reduce morbidity
and mortality (Lehrnbecher, et al., 2012; Nihal, et al., 2016).
Empirical and broad-spectrum antibiotic therapy must be immediately
given to all patients with neutropenia. Patient risk must be assessed quickly to
determine the number and spectrum of antibiotic regimens (monotherapy or
combination therapy), route of administration (parenteral or oral), and location of
care (hospital or outpatient). Patients with low risk can be defined as outpatients

with good general condition and no serious comorbidities and an estimated
duration of prolonged severe neutropenia or who have an index score of 21 or
more by using the Multinational Association for Supportive Care in Cancer
(MASCC) score (Gary & Kenneth, 2017).
Bacteria that often cause FN are Gram-positive organisms, namely
coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp.,
And strandococcal viridans. While Gram-negative bacteria, namely Escherichia
coli, Klebsiella Spp., Pseudomonas aeruginosa are often gram-negative bacteria,
although Enterobacteriaceae, Stenotrophomonas maltophilia, and Acinetobacter
spp. also many causes of neutropenia. About 10% to 15% of bacteremia that
occurs is polymicrobial with gram-negative bacteria is 80% cause of infection.
Invasive fungal infections are most commonly seen in patients with prolonged
neutropenia (Nihal, et al., 2016).
Among patients who are hospitalized, the incidence of neutropenic fever
episodes during the induction phase is 60%, however, 20% occur during the
maintenance phase. Blood flow infections (BSI) comprise the majority of MDI
(36%) followed by urinary tract infections (20%) and oral mucosal infections
(16%). The bacteria that were generally isolated were E. Coli followed by
Pseudomonas Aeroginosa and Klebsiella Pneumoniae. The first-line antibiotic
regimen in these patients at the time of hospitalization consisted of Cefaperazone
- Sulbactam (Bindu, et al., 2015).
In this patient we found the onset of fever since 1 day before admission,
and the level of leucocyte was 9310 with different count consist of eusinophil
0.3%, basophil 0%, neutrophil 2.5%, lymphocte 95.5%, monocyte 1.7 and ANC
was 230 signed as severe neutropenia. We perform laboratory work up for blood
culture and seeking for the source of infection in this patient was pneumonia. We
treat this patient with first line antibiotic for FN based on general hospital
antimicrobial guideline using Ceftriaxone 100 mg/kg body weight/day and we plan
to blood culture, urine culture, sputum and feces culture to find the cause of
infection.
4. Malnutrition
Malnutrition as an imbalance between nutrient requirement and intake,
resulting in cumulative deficits of energy, protein or micronutrients that may
negatively affect growth, development and other relevant outcomes. Ideally, any

assessment of nutrition and investigations on the role of nutrition in patient
management should include data regarding growth over a period of time: actual
dietary intake available (and provided); evidence for malabsorption; evidence of
inflammatory processes; and evidence of any underlying disease. Simple
measurements, such as height, weight, skinfold thickness or mid-upper arm
circumference, have been the basis of most definitions of nutritional status. It is
not possible to exclude malnutrition of the grounds of normal anthropometry
alone. In the assessment of nutrition status in children, inadequate caloric intake
appears to be the most important cause of malnutrition (Mehta, et al., 2013).
Figure 18. Defining malnutrition in hospitalized children

Children with malnutrition could be caused by many risk factor. (Mehta, et al., 2013)
Malnutrition defined as “an imbalance between nutrient requirement and

intake, resulting in cumulative deficits of energy, protein, or micronutrients that
may negatively affect growth, development, and other relevant outcomes”.
Ideally, any assessment of nutrition and investigations on the role of nutrition in
patient management should include data regarding growth over a period of time:
actual dietary intake available (and provided); evidence for malabsorption;
evidence of inflammatory processes; and evidence of any underlying disease
(Becker, et al., 2015).
Malnutrition can be caused primary due to poor or inappropriate food
intake, this is often happened in low sosio economic communities which the

composition and quantity of food is not sufficient resulting in nutritional disorder to
severe deficiency. Malnutrition can also be caused by secondary causes of other
diseases that result in reduced nutritional intake or adequate nutritional intake,
but increased of nutritional needs along with increased metabolic processes, for
example patient with chronic disease such as cancer (Mehta, et al., 2013).
Assessment of nutritional status in patients with malignancy is important
because malnutrition can reduce chemotherapy tolerance, increase the incidence
of infection, and decrease survival rate. Malnutrition may associated with immune
response disorders such as impaired phagocyte function, cytokine production,
antibody secretion and complement system defects. A critical review of the
prognostic value of the nutritional status in children with ALL noted that the
mortality rate for children with malnutrition was 1.8 times greater than in ALL
children with good nutrition (Guriek, et al., 2015).
Some children were malnourished at the time of diagnosis and their
malnourishment was reported to have increased during the therapy for
malignancy, especially if their treatment involved intensive chemotherapy or bone
marrow transplantation. Children treated for leukemia underwent changes in
nutritional status, as manifested by a reduction in growth, weight gain and weight
losses. A child with newly diagnosed cancer appears to have the same average
nutritional status as seen in thepopulation from which the child come, if the
diagnosis is made in a reasonably timely manner (Kadir, et al., 2017).
In general, malnutrition management should pay attention to signs of
emergencies such as dehydration, hypoglicemia, hypothermia and electrolyte
imbalance, known as the 10’s steps of inpatient treatment of severely
malnourished children. Those condition must be addressed in the stabilization
phase in 1-2 days to 1 week. During stabilization phase patient consume F75
with calculation of caloric need for a day was 50% of recommended dietary
allowance equal for his age (45 kcal) multiplied with his ideal body weight (kg),
fluid need was equal with Holliday Segar, protein need was 50% from 0.8-1
g/kg/day and micronutrient suplementation such as vitamin A 1 x 5000 IU, vitamin
C 1 x 100 mg, vitamin E 1 x 100 IU, folic acid 1 x 5 mg for first day continue with
1 x 1 mg and ZnSO 4 1 x 20 mg. Patient was also monitored hydration status and
blood sugar level periodically. During transition phase patient was given by F100
without sugar and start solid food consumption with low glicemic index, with
calculation of caloric need for a day was 75% of recommended dietary allowance

equal for his age (45 kcal) multiplied with his ideal body weight (kg), fluid need
was equal with Holliday Segar, protein need was 75% from 0.8-1 g/kg/day.
During rehabilitation phase patient still consume F100 without sugar but caloric
need raised from before which is 100% of recommended dietary allowance equal
for his age (45 kcal) multiplied with his ideal body weight (kg), fluid need was
equal with Holliday Segar, protein need was 0.8-1 g/kg/day (WHO, 2013).
Figure 19. Ten steps to recovery for the inpatient treatment of severely
malnourished children.
Phase stabilisation consist of two days to prevent the patient became hypoglicaemia
and hypothermia. Phase rehabilitation including catch-up growth and prepare the
patient for follow-up.
(WHO, 2003)
In this case, patient was diagnosed as severe malnutrition based on

clinical criteria, history of diet and anthropometry status. Patient experience
weight loss since 3 months ago. Body weight of patients was 35 kg with the
highest body weight was 45 kg 3 months ago. According to parents, patients look
thinner with clinically skinny look and thin subcuntaneous fat (impresses a
malnutrition). Based on anthropometry status, patient with body weight 35 kgs
equal to P3-P10, arm circumferrence was 15.5 cms which is below P5 and ideal
body weight percent was 77%. A careful calculation of caloric, fluid and protein
had been done. This patient had started adequate formulation for the inpatient
treatment of severely malnourished children according recommended dietary
allowance.

5. Pneumonia in the neutropenic cancer patient
Both cancer and its treatment induce derangements of innate and
adaptive immune function. Leukocyte depletion, dysregulated inflammation,
impaired pathogen recognition and graft-versushost responses contribute to
cancer patients’ tremendous susceptibility to lower respiratory tract infections.
Functional and anatomical defects frequently coexist in cancer patients. Further,
recurrent healthcare encounters that are typical among cancer patients promote
exposure to nosocomial and drug-resistant pathogens. Among the risks for
cancer-related pneumonia, neutropenia is the most prominent. Neutrophils are
sensitive to alkylating agents and nucleoside analogues, resulting in dose-
dependent reductions in the absolute neutrophil count. Severe neutropenia,
defined as a count less than 500/ml, is associated with severe lung infections
caused by bacterial and fungal organisms. The rapidity of onset, duration,
severity and underlying physiologic process all impact susceptibility to
neutropenic pneumonia. Moreover, impairments of neutrophil phagocytosis and
chemotaxis follow common cancer-related insults such as radiation,
corticosteroids, hypovolemia, acidosis and hyperglycemia Thus, functional
neutropenia can also contribute to cancer-related pneumonia risk (Meyer, et al.,
2007; Freifeld, et al., 2010: Lynn, et al., 2013).
Genuine community-acquired pneumonia (CAP), defined as development
of pneumonia in patients who have not been hospitalized or resided in a nursing
home for at least 14 days prior to the onset of symptoms, and who do not meet
criteria for other risk groups, is relatively uncommon among cancer patients,
owing to their frequent healthcare exposures. The most frequent agent of
bacterial CAP remains Streptococcus pneumoniae, including in the cancer
setting. Other causes of CAP among neutropenic patients include
Staphylococcus aureus, Pseudomonas spp. and nontypeable Hemophilus
influenzae. Streptococcus pyogenes, Neisseria meningitides and Moraxella
catarrhalis are less frequent causes of CAP (Bartlett, et al., 2000; Niederman, et
al., 2001; Mandell, et al., 2007).
Hospital-acquired pneumonia (HAP), wherein pneumonia develops at
least 48 h after hospital admission, or ventilator-associated pneumonia, which
develops more than 48–72 h after endotracheal intubation. Mortality rates
associated with drug-resistant P. aeruginosa and methicillin resistant S. aureus

(MRSA) are disproportionately higher than those caused by other nosocomial
bacterial pathogens. (El-Solh, et al., 2002; Mandell, et al., 2003; Maschmeyer G,
2011).
Although bacterial pathogens cause documented neutropenic
pneumonias about twice as often as fungi, invasive pulmonary mycoses are
associated with significant morbidity and mortality. Aspergillus is the most
common fungal pneumonia in neutropenic patients. Non-Aspergillus moulds such
as Fusarium spp., Pseudaalesheria boydii, Scedosporium spp. and the
dematiaceous moulds that are often not susceptible to conventional antifungal
agents are also described in this population (El-Solh, et al., 2002; Yoshida, et al.,
2011; Mulanovich & Kontoyiannis, 2011; Lanoix, et al., 2012).
The classical clinical signs of pneumonia in most populations include new
pulmonary infiltrates, leukocytosis, fever and purulent secretions. However, due
to disordered host inflammatory responses in the neutropenic cancer patient,
these clinical and radiographic hallmarks may be unapparent. Early computed
tomographic (CT) scanning is warranted for neutropenic patients with
unanticipated clinical deterioration, unexplained fevers or questionable infiltrates
on conventional imaging. Thus, although infection remains the most frequent
cause of these radiographic abnormalities in neutropenic patients, the potential
diagnoses are numerous and the challenge is to identify those patients who are
most likely to benefit from further investigations in addition to empiric
antimicrobial therapy (Mulanovich & Kontoyiannis, 2011; Lanoix, et al., 2012;
Maschmeyer, et al., 2015).
Neutropenic pneumonia is most reliably diagnosed when a likely
pathogen is recovered from a typically sterile site or when a noncommensal
organism is isolated from respiratory secretions. Although practice patterns vary
widely, bronchoscopy with bronchoalveolar lavage (BAL) is the diagnostic tool of
choice for obtaining lower respiratory samples from neutropenic cancer patients.
BAL is well tolerated for most cancer patients, although traditional culture
methods yield a definite pathogen in only 25–51% of cases (Sampsonas, et al.,
2011; Wahla, et al., 2014).
Treatment should generally not be withheld while diagnostic interventions
are undertaken. Delays in appropriate antimicrobial therapy increase the risk of
secondary complications and infection-associated deaths in neutropenic patients,
thus it is common practice to initiate empiric and/or pre-emptive antimicrobial

therapy when neutropenic pneumonia is suspected. Initial antimicrobial therapy
for febrile neutropenia in patients with pulmonary infiltrates cover the broad range
of pathogens described above (Freifeld, et al., 2010; Weissinger, et al., 2012;
Maschmeyer, et al., 2015).
Despite broad-spectrum antimicrobial strategies, mortality rates remain
high in neutropenic patients. These antimicrobial failures arise, at least in part,
from the continuing immune defects associated with the neutropenia. Therapeutic
strategies still must rely on early recognition and initiation of broadspectrum
antibacterial and antifungal therapy in appropriate patients. New host-directed
therapies that help to reconstitute the immune system and others that stimulate
epithelial innate immunity are under investigation in clinical trials (Rawlins &
Hogan, 2008; Cleaver, et al., 2014).
In this patient we found high fever with cough and respiratory distress
since seven days before admission. The radiology finding of this patient is
infiltrate in both lung with conclusion is pneumonia. Patient got antibiotic
intravenous Ceftriaxone dose 100 mg/kg/day divide two times a day and we plan
to sputum culture to find the cause of pathogen.
6. Acute Diarrhea
Gastrointestinal complications are common in patients undergoing various

forms of cancer treatment, including chemotherapy, radiation therapy, and
molecular-targeted therapies. Many of these complications are life-threatening
and require prompt diagnosis and treatment. Complications of oncologic therapy
can occur in the esophagus (esophagitis, strictures, bacterial, viral and fungal
infections), upper gastrointestinal tract (mucositis, bleeding, nausea and
vomiting), colon (diarrhea, graft–versus–host disease, colitis and constipation),
liver (drug hepatotoxicity and graft–versus–host disease), and pancreas
(pancreatitis). Diarrhea is a frequent complication in children with cancer.
Possible etiologies include radiotherapy, chemotherapy, graft versus host
disease and infections. Diarrhea can be debilitating and, in some cases, life-
threatening, causing volume depletion, renal failure and electrolyte disorders
(Castagnola, et al., 2016).
Neutropenic enterocolitis (NE) is a specific disease entity, usually

manifesting itself with diarrhea. It is a severe complication of chemotherapeutic

regimens. The acute inflammatory disease may involve cecum, colon and the
terminal part of the ileum. The mechanism by which NE occurs is mutifactorial
and thought to result from a combination of multiple factors, including
neutropenia, chemotherapy- or radiotherapy-induced destruction of normal
mucosa, intramural hemorrhage caused by severe thrombocytopenia and change
in normal gastrointestinal flora caused by antibiotics, antifungal agents and
colonization by hospital flora. The exact pathogenesis is also unknown, and may
contribute to the varied nomenclature in use. Gut mucosal ulcerations may result
from direct drug-related cytotoxicity, or from neutropenia itself. Microbial invasion
of the bowel wall proceeds unimpeded. Pathological changes include
inflammation and edema, presumably followed by ulceration, transmural
necrosis, and perforation (Sherief, et al., 2012).
The classic clinical presentation consists of fever, abdominal pain, and

neutropenia, but diagnosis is often hindered by subtle or non-specific clinical
findings, making computed tomography the linchpin of diagnosis. The wide
spectrum of clinical presentation requires an individualized approach to therapy.
Prolonged neutropenia appears to be the pre-requisite factor in conjunction with
injury to the bowel mucosa. The diagnosis of NE may be delayed because the
presenting clinical features (fever, abdominal pain and diarrhea) are not specific
and may suggest other abdominal diseases. To support the clinical diagnosis of
NE, imaging techniques have therefore been used, including abdominal
ultrasonography and computed tomography (Sherief, et al., 2012).
Enterocolitis is a necrotizing infflamatorry lesion involving the terminal

ileum, cecum and ascending colon, can be a presenting syndrome or can occur
during treatment. Neutropenic enterocolitis was diagnosed if the patient fulfilled
the following criteria: fever (axillary temperature >38.0°C); diarrhea with or
without other abdominal symptoms (abdominal pain, tenderness, rebound
tenderness, etc.) and bowel wall thickening on imaging. Fever, abdominal pain
and bloody diarrhea, or ileus may be present and ccasionally mimic appendicitis-
intestinal perforation, an infflamatorry mass and associated infection with enteric
gram-negative bacilli or clostridial species are often associated with a fatal
outcome. Isolated involvement of the gastrointestinal tract is rare. Netropenic
enterocilitis (NE) which is a fulminant necrotizing process is well recognized
complication of netropenia in patients dying from hematologic malignancies

especially acute leukemia as indicated by various autopsy series. Neutropenic
enterocolitis is a specific disease entity, usually manifesting itself with diarrhea. It
is thought to be associated with chemotherapy-induced mucosal injury, followed
by a superinfection usually by Gram-negative bacteria and may lead to
bacteremia. However, others such as fungi and viral pathogens can also be
identified. Neutropenic enterocolitis may be seen in patients with solid tumors,
aplastic anemia and neutropenia due to some other causes, but most cases are
reported in those with acute leukemia. (Mehdi, et al., 2012; Gamal, et al., 2013)
Although the classical triad of neutropenic enterocolitis—fever, abdominal

pain and diarrhea—has been used as diagnostic criteria for many years, there is
considerable overlap between neutropenic enterocolitis and other causes of
diarrhea. Mucositis-related diarrhea, C. difficile-associated colitis, ischemic colitis,
bacterial and viral colitides, parasitosis and surgical pathologies should be
differentiated from neutropenic enterocolitis (Aksoy, et al., 2007).
In this patient suffered from high fever and diarrhea without dehydration. It
maybe caused by the enterocolitis. Patient got per oral zinc 20 mg a day to repair
the function of gastro intestinal villi for ten days.
7. Acute tonsilitis
Tonsillitis most often occurs in children; however, the condition rarely

occurs in children younger than 2 years. Tonsillitis caused
by Streptococcus species typically occurs in children aged 5-15 years, while viral
tonsillitis is more common in younger children. Pharyngitis accompanies many
upper respiratory tract infections. Between 2.5% and 10.9% of children may be
defined as carriers. In one study, the mean prevalence of carrier status of
schoolchildren for group A Streptococcus, a cause of tonsillitis, was 15.9%.
Pediatric tonsil cancer is rare with the existent literature largely limited to small
case series. Patient with malignancy such as acute lymphoblastic leukemia or
non-hodgkin lymphoma could have enlargement tonsil (Laranaga, et al., 2007;
Uhler, et al., 2013; Ealam, et al., 2018).
Actually for this patient suffered from tonsillitis because of viral infection.
This patient in immunocompromized state because of his severe neutropenia that
lead the infection. Total Centor Score 4 it means need antibiotics

8. Psychosocial Support and Counseling
Young adulthood is a time of increased vulnerability to stress and

presents young people diagnosed with cancer with major developmental
challenges above and beyond those faced by other young people, for example,
gaining independence, establishing one's sense of identity, negotiating
interpersonal relationships (including intimacy, forming families, and caring for
dependents), as well as making important decisions about education and
employment. The medical, cognitive, and psychosocial effects of cancer
treatment are likely to impact significantly on these challenges. A diagnosis of
cancer during adolescence and young adulthood creates unique emotional,
social, physical, and financial crises. The inability to cope during this period can
be a precipitating factor in the development of long-term problems, suggesting
the importance of early psychosocial intervention to reduce distress and manage
treatment-related symptoms (Zebrack, et al., 2014; Penn & Kuperberg, 2018).
The prevalence of psychological distress in adolescent cancer patients is

higher than in the general cancer population,18 with risk of increasing during the
first year following diagnosis. Significant distress among patients with cancer
varies, ranging from 6% to 41% in independent cross-sectional studies with
varying sample sizes, age ranges, timing of data collection, and tools utilized. A
young person who exhibits good coping during the early stages of the cancer
journey may require additional support and guidance to manage the changing
stress levels during active treatment. This calls for continuous screening, risk
assessment for adherence, and informal catch-ups with patients and families
throughout the continuum of care. To help young cancer patients adjust and
manage their cancer experience, it is essential to establish patient-provider
connectedness. Understanding how to engage this population requires
recognition of the cognitive capabilities and unique developmental challenges
associated with adolescence and young adulthood. Adolescents and young
adults typically express preferences for face-to-face communication with health
professionals that is open, honest, nonjudgmental, respectful, and inclusive of
them in the formulation of treatment plans.For this age group, open
communication about their diagnosis and prognosis at the initial stage of disease

also showed significantly less anxiety and depression further down the cancer
pathway (Kazak, et al., 2015; Penn, et al., 2017).
Research on patients with chronic illness found that interventions directed

at changing illness perceptions can improve selfmanagement behaviors. Efforts
to provide such intervention should be routine not only for the patient but also for
the caregiver. Thus, efficacious psychotherapy interventions may require
consideration of both patients' and caregivers' perceptions of illness severity.
Empowering the young person with cancer is key to symptom management. The
experience of an illness such as cancer is a profoundly social one. The provision
of social support can help teens and young adults with cancer cope with their
illness and overcome the feeling that they are alone. Kyngas et al. found that
social support was the major coping strategy used by adolescents to deal with
cancer, with support coming from family, friends, and health care providers.
Family and friends are most commonly reported as the major sources of social
support by adolescent patients. However, social support groups may also provide
an important source of support for adolescents treated for cancer. For some
adolescents, meeting with others of the same age with cancer has been reported
as being more helpful with coping than support from family and friends. Given the
significance of peer relationships during adolescence and young adulthood and
the reality that a cancer diagnosis may lead to physical and emotional isolation,
peer-based interventions can play an important role in development and
psychological adjustment and decreased distress and anxiety. Young adults with
cancer ranked the opportunity to meet other young adults with cancer as being
one of their top supportive care needs, regardless whether on or off treatment
(Kyngas, et al., 2001; Ahmad, et al., 2016; Ishibashi, et al., 2016).
Given the fact that the adolescents' mode of coping is often associated
with their support from a peer group, both organized and informal groups can
play an important role in this area. Social interaction may take many forms
including face-to-face weekly meetings, online groups, weekend retreats,
conferences, and adventure therapy trips and is important in promoting the
successful achievement of age-related developmental tasks. Actively seeking
support has been demonstrated to be associated with positive adjustment, and
participation in social support groups may help to reduce stress and anxiety and
promote an active lifestyle for adolescents with cancer. Most studies on therapy

groups for adolescents are qualitative and descriptive but in general show that
group interventions can be effective. Group interaction in various peer support
programs allows members to feel that they give as well as receive, which can
serve to enhance self-esteem, lessen feelings of powerlessness, and give
meaning and purpose to the illness experience. The opportunity to share with
others provides a sense of normalcy, builds community, and reduces the sense
of isolation so common among cancer patients (Meijer, et al., 2002; Treadgold &
Kuperberg, 2010; Stenenga, 2014).
Several studies identify family support and cohesiveness as important

contributors to positive adjustment and family functioning as the single best
predictor of distress, with poorer family functioning predictive of greater distress.
There is also strong evidence that cancer is a dyadic illness shared between
patients and their caregivers and that interventions should target this dyad rather
than treat as independent individuals. Whether caregivers are parents, spouse,
or even siblings, psychosocial interventions for all family members should be
integral in provision of supportive care services. Research on patients with
chronic illness found that interventions directed at changing illness perceptions
can improve selfmanagement behaviors. Efforts to provide such intervention
should be routine not only for the patient but also for the caregiver. Thus,
efficacious psychotherapy interventions may require consideration of both
patients' and caregivers' perceptions of illness severity Parenting while
undergoing cancer treatment can be a great source of distress, yet few parenting
interventions to help with parental distress and poor family communication exist.
Parents and their children alike may be at risk of poor psychosocial outcomes.
Findings from a novel and assessable psychoeducational intervention to improve
parenting efficacy and decrease parental stress provide a template to be used to
help parents and their children (Levin, et al., 2000; Juth, et al., 2015; Stafford., et
al., 2017).
Adolescents and young adult patients and survivors confront myriad

disruptions in the worlds of school and work as a direct result of cancer diagnosis
and treatment. Returning to school or work represents the continuation of
“normal” life. Lower educational attainment and unemployment, among other
variables, have also been identified as risk factors for psychological distress and
poor health-related quality of life, highlighting the importance of attendance at

school and work. Young adults are more likely to be uninsured or to have very
limited health insurance when compared with children or older adults. Some may
experience difficulty maintaining or obtaining independent or family-based health
insurance, encounter financial strain, and attain lower income levels when
compared with other noncancer groups (Zeltzer, et al., 2009; Oeffinger, et al.,
2004).
In this patient, according to Pediatric Quality of Life Inventory (PedsQL)

pediatric cancer value of 50% means that there is decreasing quality of life .
Therefore patients need assistance in psychosocial aspects. There is a
significant amount of work being done to improve the physical, psychological, and
social status of cancer patients. There is a necessity for high-quality intervention
studies that include, ideally, assessment of long-term benefit and
costeffectiveness to ensure such interventions are available to the majority of
adolescent cancer patients. The assistance can be in the form of counseling
about psychological and psychosocial support that can be done by people who
are directly or indirectly involved in patient care. Psycotheraphy to patient and
family theraphy are needed to be done in this patient. This support has strategic
importance and is important in efforts to improve quality and extend the life
expectancy of patients. This is important because psychosocial support will
influence behavior and physical appearance, including individual body
endurance. In this patient counseling to the patient's parents regarding the
condition of the patient's disease, the possibility to live as normal as possible, the
importance of obedience to long-term treatment, the worst possibility that can
occur as a result of the disease or long-term treatment and prognosis and the
importance of psychosocial support has been sought through family and health
workers who took care of him.
9. Prognosis
The remission induction rate was 95%, the induction mortality rate was
2.6% and overall survival was 72%. The survival rate of pediatric ALL patients
has improved toapproximately 90% in recent years, especially for groups
withgood prognosis. This progress is mainly due to the adoption ofmodifications
in therapy based on patients’ individual phar-macodynamics and
pharmacogenomics, risk-adapted therapyand improved supportive care. The
estimated survival rates found were inferior to the results obtained in developed

countries. The 5-year even free survival rate was lower than that reported in the
literature. However, low-risk patients had a better prognosis (Pui, et al., 2008;
Möricke, et al., 2008).
It is known that the mortality rate related to fungal infec¬tions is high in
neutropenic patients. In high risk neutropenic patients, the mortality rate related
with systemic candidiasis has been reported to be 50% and to invasive
aspergillosis as high as 80-100% (Möricke, et al., 2008). For the conclusion, this
patient with prognosis vitam, sanationam and functional are dubia ad malam.
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JOURNAL REFERENCES
1. Rachel T. Dank, Ann Ran DB. 2016. Clinical Presentation of Childhood

Leukaemia: A Systematic Review and Meta analysis. Archive of Disease
in Childhood, Volume 110, Issue: 10.

Conclusion: Over 50% of children with leukaemia have palpable livers,
palpable spleens, pallor, fever or bruising on diagnosis. Abdominal
symptoms such as anorexia, weight loss, abdominal pain and abdominal
distension are common. Musculoskeletal symptoms such as limp and joint
pain also feature prominently. Children with unexplained illness require a
thorough history and focused clinical examination, which should include
abdominal palpation, palpation for lymphadenopathy and careful scrutiny
of the skin.
Level of Evidence and recommendation: II-A
2. Özdemir, N., Tüysüz, G., Çelik, N., Yantri, L., Erginöz, E., Apak, H.,
Özkan, A., Yıldız, İ. and Celkan, T., 2016. Febrile neutropenia in children
with acute lymphoblastic leukemia: single center experience. Turkish
Archives of Pediatrics/Türk Pediatri Arşivi. Retrospective cohort study.
Conclusion : the incidences of febrile neutropenia during initial treatment
and during relapse treatment were compared, it was observed that more
febrile neutropenia attacks occured during relapse treatment. Fifty-nine
percent of all febrile neutropenia attacks were fever of unknown origin.
Coagulase negative staphylococcus (n=17) was the most frequent gram
positive pathogen; E. Coli (n=17) was the most commonly grown gram
negative pathogen. Increments in treatment intensities increase the
incidence of febrile neutropenia while improving survival. Evaluation of
febrile neutropenia results by hematology-oncology units in years will be
directive in early and successful treatment.
Level of Evidence and recommendation: II-B
3. Eden. TOB, Pieters. R, Richard. S. 2009. Beneficial and Harmful effect of
Anthracyclines in the treatment of Childhood Acute Lymphoblastic
Leukeumia: A Systematic Review and Meta analysis. Childhood Acute
Lymphoblastic Leukaemia Collaborateive Group (CALLCG)
Conclusion: Anthracyclines significantly reduced bone marrow relapse
when added to standard therapy but did not significantly increase event‐
free survival. There were no significant differences in any relapse, event
or death between any anthracycline derivatives, between 48 or 24 and 1h
anthracycline infusions or between treatment with or without the
cardioprotectant dexrazoxane. Keeping cumulative doses below 300

mg/m2 appears to reduce cardiotoxicity but there is no clear evidence that
other strategies have an effect.
Level of Evidence and Recommendation: I-B
4. Robinson. PD, Lernchbecher. T. 2016. Strategies for Empiric
Management of Pediatrics Fever and Neutropenia in Patients with cancer
and Hemoepoetic stme cell transplantation Recipients: A systematic
Review of Randomized Trials. Journal of Clinical Oncology 34, No. 17,
2054 – 2060.
Conclusion: There were a moderate number of pediatric randomized trials
of febrile neutropenia management. Monotherapy for high-risk febrile
neutropenia and outpatient and oral management for low-risk febrile
neutropenia are effective strategies. These findings will provide the basis
for guideline recommendations in pediatric febrile neutropenia.
Level of Evidence and Recommendation: I-A
5. Manji. A, Lerchnbecher. T, Sung. L. 2011. A Systematic Review and
Meta-Analysis of anti-pseudomonal Penicillin and carbapenems in
Pediatrics Febrile Neutropenia. Suporter care in Cancer, Volume 20,
Issue : 10, 2295 – 2304.
Conclusion: Our meta-analysis suggests that APP–aminoglycoside, APP
monotherapy, and carbapenem monotherapy are all efficacious
therapeutic options for the empiric management of pediatric febrile
neutopenia.
Level of Evidence and Recommendation: I-B

6. Søgaard, K.K., Farkas, D.K. and Sørensen, H.T., 2017. Pneumonia
diagnosis in childhood and incidence of leukaemia, lymphoma and brain
cancer: a Danish nationwide cohort study. BMJ open, 7(12), p.e019860.
Population-based cohort study.
Conclusion : The cancer incidence ratio were substantially increased
during the first 6 months of follow-up; lymphoid leukaemia: 6.2 (95% CI
3.5 to 10.3).
Level of Evidence and Recommendation: II-B
7. Oskarsson, T., Söderhäll, S., Arvidson, J., Forestier, E., Montgomery, S.,
Bottai, M., Lausen, B., Carlsen, N., Hellebostad, M., Lähteenmäki, P. and
Saarinen-Pihkala, U.M., 2016. Relapsed childhood acute lymphoblastic

leukemia in the Nordic countries: prognostic factors, treatment and
outcome. haematologica, 101(1), pp.68-76. Systematic review.
Conclusion : Factors independently predicting mortality after relapse
included short duration of first remission, bone marrow involvement, age
ten years or over, unfavorable cytogenetics, and Down syndrome. T-cell
immunophenotype was not an independent prognostic factor unless in
combination with hyperleukocytosis at diagnosis. The outcome for early
combined pre-B relapses was unexpectedly poor (5-year overall survival
38.0±10.6%).
Level of Evidence and Recommendation: II-A
8. Agnes. M, Widjajanto. PH, Damayanti. W. 2008. Impact of Malnutrition of

Febrile Neutropenia in children with Acute Lymphoblastic Leukemia
during Induction Phase Chemotherapy. Pediatric Hemato-Oncology,
Volume 58, Issue: 6
Conclusion: Malnutrition is a risk factor for Febrile Neutropenia in children
with acute lymphoblastic leukemia.
Level of Evidence and Recommendation: III-B
ABBREVIATIONS

ALL : Acute lymphoblastic leukemia
ALT : Alanine Transaminase
ANC : Absolute neutrophil count
AST : Aspartate Aminotransferase
BAL : Bronchoalveolar lavage
BCG : Bacillus Calmette Guerin
BSI : Blood flow infections
CAP : Genuine community-acquired pneumonia
Cms : Centimeters
CNS : Central Nervous System
DPT : Difteri Pertusis Tetanus
DT : Difteri Tetanus
FAB : French-American-British
FN : Febrile Neutropenia
FNAB : Fine Needle Aspiration Biopsy
GCS : Glasgow Coma Scale
HAP : Hospital-acquired pneumonia
Hb : Haemoglobin
Hct : Hematocrit
IBW : Ideal Body Weight
ICS : Inter Costal Space
Kg : Kilograms
KMS : Kartu Menuju Sehat

MASCC ; Multinational Association of Supportive Care in Cancer
MCH : Mean Corpurscular Hemoglobin
MCV : Mean Corpurscular Volume
Ml : Milliliters
MR : Measles Rubella
MRSA : Methicillin Resistant S. Aureus
NE : Neutropenic Enterocolitis
PedsQL : Pediatric Quality of Life Inventory
Plt : Platelet
PRC : Packed Red Cell
RBC : Red Blood Cell
RDA : Recommended Dietary Allowances
RDW : Red Cell Distribution Width
SD : Standard Deviation
TC : Trombosit
TT : Tetanus Toxoid
TR : Tricuspid Regurgitation
Attachment 1. Patient’s vital signs graphic monitoring during observation.

120
100
80
Temperature
HR
60 RR
SpO2 (%)
SBP
40 DBP
20
0
3-Oct 4-Oct 5-Oct 6-Oct 7-Oct 8-Oct 9-Oct
Attachment 2. Patient’s fluid balance and urine production monitoring

during observation.
4
2
0
3-Oct 4-Oct 5-Oct 6-Oct 7-Oct 8-Oct 9-Oct
-2
-4
Fluid Balance
-6 TBW (%)
Urine Prod
-8
-10
-12
-14
-16

ID#
Date:
™
PedsQL
Cancer Module
Version 3.0
TEEN REPORT (ages 13-18)
DIRECTIONS
Teens with cancer sometimes have special problems. Please tell us how much of a
problem each one has been for you during the past one month by circling:
1 if it is never a problem
2 if it is almost never a problem
3 if it is sometimes a problem
4 if it is often a problem
5 if it is almost always a problem
There are no right or wrong answers.
If you do not understand a question, please ask for help.

In the past one month, how much of a problem has this been for you …
PAIN AND HURT (problems with…) Never Almost Some- Often Almost
Never tims Always
1. I ache or hurt in my joints and/or muscles 0 1 2 3 4
2. I hurt a lot 0 1 2 3 4
NAUSEA (problems with…) Never Almost Some- Often Almost

Never times Always
1. I become sick to my stomach when I have medical 0 1 2 3 4
treatments
2. Food does not taste very good to me 0 1 2 3 4
3. I become sick to my stomach when I think about
0 1 2 3 4
medical treatments
4. I feel too sick to my stomach to eat 0 1 2 3 4
5. Some foods and smells make me sick to my 0 1 2 3 4
stomach
PROCEDURAL ANXIETY (problems with…) Never Almost Some- Often Almost

Never times Always
1. Needle sticks (i.e. injections, blood tests, IV’s) hurt 0 1 2 3 4
2. I get scared when I have to have blood tests 0 1 2 3 4
3. I get scared about having needle sticks (i.e.
0 1 2 3 4
injections, blood tests, IV’s)
TREATMENT ANXIETY (problems with…) Never Almost Some- Often Almost

Never times Always
1. I get scared when I am waiting to see the doctor 0 1 2 3 4
2. I get scared when I have to go to the doctor 0 1 2 3 4
3. I get scared when I have to go to the hospital 0 1 2 3 4
WORRY (problems with…) Never Almost Some- Often Almost

Never times Always
1. I worry about side effects from medical treatments 0 1 2 3 4
2. I worry about whether or not my medical treatments
are working 0 1 2 3 4
3. I worry that my cancer will come back or relapse 0 1 2 3 4
COGNITIVE PROBLEMS (problems with…) Never Almost Some- Often Almost

Never times Always
1. It is hard for me to figure out what to do when
0 1 2 3 4
something bothers me
2. I have trouble solving math problems 0 1 2 3 4
3. I have trouble writing school papers or reports 0 1 2 3 4
4. It is hard for me to pay attention to things 0 1 2 3 4
5. It is hard for me to remember what I read 0 1 2 3 4

PERCEIVED PHYSICAL APPEARANCE Never Almost Some- Often Almost
Never times Always
(problems with…)
1. I feel I am not good looking 0 1 2 3 4
2. I don’t like other people to see my scars 0 1 2 3 4
3. I am embarrassed when others see my body 0 1 2 3 4
COMMUNICATION (problems with…) Never Almost Some- Often Almost

Never times Always
1. It is hard for me to tell the doctors and nurses how I
0 1 2 3 4
feel
2. It is hard for me to ask the doctors and nurses
0 1 2 3 4
questions
3. It is hard for me to explain my illness to other
0 1 2 3 4
people

ID#
Date:
™
PedsQL
Cancer Module
Version 3.0
PARENT REPORT for TEENS (ages 13-18)
DIRECTIONS
Teens with cancer sometimes have special problems. On the following page is a list of
things that might be a problem for your teen. Please tell us how much of a problem
each one has been for your teen during the past one month by circling:
1 if it is never a problem
2 if it is almost never a problem
3 if it is sometimes a problem
4 if it is often a problem
5 if it is almost always a problem
There are no right or wrong answers.
If you do not understand a question, please ask for help.
91
In the past month, how much of a problem has your teen had with …
PAIN AND HURT (problems with…) Never Almost Some- Often Almost
Never times Always
1. Aches in joints and/or muscles 0 1 2 3 4
2. Having a lot of pain 0 1 2 3 4
NAUSEA (problems with…) Never Almost Some- Often Almost

Never times Always
1. Becoming nauseated during medical treatments 0 1 2 3 4
2. Food not tasting very good to him/her 0 1 2 3 4
3. Becoming nauseated while thinking about medical
0 1 2 3 4
treatments
4. Feeling too nauseous to eat 0 1 2 3 4
5. Some foods and smells making him/her nauseous 0 1 2 3 4
PROCEDURAL ANXIETY (problems with…) Never Almost Some- Often Almost

Never times Always
1. Needle sticks (i.e. injections, blood tests, IV’s)
0 1 2 3 4
causing him/her pain
2. Getting anxious about having blood drawn 0 1 2 3 4
3. Getting anxious about having needle sticks (i.e.
0 1 2 3 4
injections, blood tests, IV’s)
TREATMENT ANXIETY (problems with…) Never Almost Some- Often Almost

Never times Always
1. Getting anxious when waiting to see the doctor 0 1 2 3 4
2. Getting anxious about going to the doctor 0 1 2 3 4
3. Getting anxious about going to the hospital 0 1 2 3 4
WORRY (problems with…) Never Almost Some- Often Almost

Never times Always
1. Worrying about side effects from medical treatments 0 1 2 3 4
2. Worrying about whether or not his/her medical
treatments are working 0 1 2 3 4
3. Worrying that the cancer will reoccur or relapse 0 1 2 3 4
COGNITIVE PROBLEMS (problems with…) Never Almost Some- Often Almost

Never times Always
1. Difficulty figuring out what to do when something
0 1 2 3 4
bothers him/her
2. Trouble solving math problems 0 1 2 3 4
3. Trouble writing school papers or reports 0 1 2 3 4
4. Difficulty paying attention to things 0 1 2 3 4
5. Difficulty remembering what he/she reads 0 1 2 3 4
92
In the past one month, how much of a problem has your teen had with …
PERCEIVED PHYSICAL APPEARANCE Never Almost Some- Often Almost

Never times Always
(problems with…)
1. Feeling that he/she is not good looking 0 1 2 3 4
2. Not liking other people to see his/her scars 0 1 2 3 4
3. Being embarrassed about others seeing his/her
0 1 2 3 4
body
COMMUNICATION (problems with…) Never Almost Some- Often Almost

Never times Always
1. Difficulty telling the doctors and nurses how he/she
feels 0 1 2 3 4
2. Difficulty asking the doctors or nurses questions 0 1 2 3 4
3. Difficulty explaining his/her illness to other people 0 1 2 3 4
93
Attachment 3. National chemotheraphy protocol of Acute Lymphoblastic
Leukemia 2018
PROTOKOL NASI ONAL LEUKEMI A LI MFOBLAS TI K AKUT 2018

RISIKO TINGGI
Nama: …………………………………………….
Tgl. Lahir: …………….. Tgl. Diagnosis: ……………… No. RM: …………………………
OB AT Do s is INTENS IFIKAS I (REINDUKS I)

(minggu) 14 15 16 17
Mtx + De ks a m e ta s o n : it
Vinc ris tin: 1 ,5 mg / m² iv
De ks a me ta s o n: 6 mg m ² po
Da uno rubic in * : 3 0 mg / m ² iv
Cita ra bin: 7 5 m g / m ² iv
hari
Tgl terapi bulan
tahun
BB ( kg )
TB ( cm )
LPB ( m2 )
Supervisor,
Catatan:
*) Bila daunorubicin tidak ada, diganti doxorubicin 20 mg/m2
………………………………….
PROTOKOL NASI ONAL LEUKEMI A LI MFOBLAS TI K AKUT 2 0 1 8

RISIKO TINGGI
8 9 10 11 12 13
Mtx + Deks ame tas o n: it
Cyc lo pho s phamide : 1000 mg /m2
Blas t CSS
hari
bulan
tahun
BB ( kg )
TB ( cm )
Supervisor, Catatan :
H idrasi pra-MTX cairan D5 1/4NS atau D5 1/2NS atau NS (sesuai umur) 2000 ml/m2/hari + Bicnat 25 mEq/500 mL selama 12 jam
H idrasi pasca-MTX diberikan selama 24 jam kecuali dalam kondisi tertentu dapat diperpanjang
C SS = Cairan Serebro Spinal
94
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LONGITUDINAL CASE

Acute Lymphoblastic Leukemia - L II (C91.00),

Severe Neutropenia (D70.3), Febrile Neutropenia (D70.9),

Severe Anemia (D61.9), Pneumonia (J18.9),

Marasmic Type Malnourishment (E41), Acute Diarrhea without

Dehydration (R19.7), Acute Tonsilitis (J03.90)

Nindy Resti Rahayu, MD

Malang, October 10th 2019

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 1

Name : Nindy Resti Rahayu

Date of entry as resident : July, 1st 2015

Regional board date : October 10th 2019

Date of Birth : June 18th, 2006

Medical Record No. : 11457052

Date of Hospitalization : October 1st, 2019

The Commencement : October 3st, 2019

Name : Mr. R Mrs.A

Age : 35 years-old 30 years-old

Education : Senior High School Junior High School

Occupation : Farmer Farmer

Religion : Moslem Moslem

Address : Dsn. Surorowo RT1/6 Kayukebek, Tutur, Pasuruan

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 2

Present Medical History

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 3

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 4

Figure 1. Family Tree

Maternal History & Antenatal Care

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 5

Growth and Development History

Sit-no support : 6 months-old

Stand alone : 11 months-old

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 6

Table 2. Patient Immunization Timetable

Conclusion: Basic immunization according to Ministry of Health’s program was complete.

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 7

Figure 2. View of environment surroundings of patient.

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 8

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 9

(at Emergency Ward, General Hospital)

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 10

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 11

Figure 6. Head Circumference of the patient is 52.5 cm (-2 SD until Mean)

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 12

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 13

Mouth : wet mocous surface, pale (+)

Figure 8. tonsil of the patient. enlargement of tonsil, T2/T2.

Palpation : ictus cordis not palpable

Upper right border : ICS II right parasternal line

Lower right border : ICS IV right parasternal line

Upper left border : ICS II left parasternal line

Longitudinal Case-Local Evaluation, Malang October 10th, 2019 14

Auscultation : normal heart sound, murmur (-), gallop (-)

Inspection Symetrical, minimal Symetrical, minimal

Palpation Normal Normal

Percussion Sonor Sonor

Auscultation Breath sound vesicular, Breath sound vesicular,

Posterior Right Left

Inspection Symetrical Symetrical

Palpation Normal Normal

Perkusi Sonor Sonor

Auscultation Breath sound vesicular, Breath sound vesicular,

Abdomen Inspection: umbilicus potruded, collateral vein not visible