Hyperleukocytosis

ec ALL
Supervisor:

dr. Cece Alfalah, M.Biomed, Sp.A(K)

Presented by:
Aryati Ningsih
Nurul Hasanah Surury
Rika Wandarai

PEDIATRIC DEPARTMENT OF
MEDICAL FACULTY OF RIAU UNIVERSITY
Hyperleukocytosis
• WBC : >100.000/uL
• This situation is an emergency in oncology that requires
immediate action because it can cause life-threatening
complications of patients
• Complications that can occur include leukostasis and
tumor lysis syndrome
• Hyperleukocytosis found in 9-13% patients with ALL
• ALL is the most often of acute leukemia

Abdulsalam M. 20054
Epidemiology
INDONESIA 9-13% with ALL
Incidence

Hyperleukocytosis : WBC RIAU

>100.000/uL
ALL: 79,2%

Fridayenti. 20155
CASE REPORT
Identity
– Name : An. G
– No MR : 981045
– Address : Desa Telayap, Pangkalan Kerinci
– Religion : Kristen
– Ethnic : Batak
– Father : Mr. R
– Mother : Mrs. N
– Date of admission : 5th April 2018
– Date of examination: 5th April 2018
Anamnesis
• Chief Complaint:

Pale since 2 Months ago

 History of Present Illness
Pale 2 Fatigue, berkunang- Knee
months kunang tenderness

loss of appetite and

Three mass
loss of weight
of the neck

Bleeding sign (-)

The same complaint one month ago (+)
 Pregnancy • Partus 3, SC, aterm
History • weight : 3800 g, length : -

Parents • Mother / housewife

History • Father / private employees

• Malignancy (-)
Family History • Same complaint (-)
 • 0-6 months : ASI
Dietary • 6 months – 2 years : ASI + MPASI
• 2 years – now : Daily food

Vaccination • Hep B 1x
Physical examination
General appearance : Moderate Illness
Awareness : Composmentis
Vital signs:
-Blood pressure : 100/70 mmHg
-Pulse : 90 x/min
-Respiratory rate : 20 x/min
-Temperature : 36,8ºC
Nutrition : - Height : 140 cm
- Weight : 29 kg
- LILA : 20 cm
Nutritional status : Good Nutrition
Physical examination
Normocephal, ear and nose
within normal limit.
Bleeding mark in mucose (-)
Neck stiffness (-)
Lymph nodes
enlargement (+) firm
concistency,
tenderness (-), mobile,
smooth.
Pale conjunctiva (+/+),
yellow sclera (-/-),
Light reflex (+/+), isochoric
pupil  2 mm,
Inspection: symmetrical chest
wall movement left and right,
retraction (-)
Palpation: symmetrical vocal
fremitus left and right lung
Percussion: resonant in both
lungs
Auscultation: Vesicular (+ / +),
ronkhi (-/-), wheezing (-/-)
Inspection : Ictus cordis was invisible
Palpation : palpable in the left midclavicle line, ICS V
Percussion : no cardiomegaly
Auscultation: S1 S2 regular (+), murmur (-), gallop (-)
Physical examination

Inspection : Flat, scar (-), venectation

(-)
Auscultation : bowel sound (+) 8
times a minute
Palpation : supel, epigastric pain (-),
hepatomegaly (+), splenomegaly
(+) S2-S3
Male, normal forms, Percussion: Timpani (+), shifting
congenital anomalies (-) dullness (-)
, normal testis.

Warm, CRT <2 seconds,

edema(- /-),
cyanosis (- / -)
Lab Work up
Darah rutin (05/04/2018)
□ Hemoglobin : 3,4 g/dL
□ Hematokrit : 11,8%
□ Leukosit : 495.740/µL
□ Trombosit : 24.000/µL
□ Eritrosit : 1.350.000/µL
□ MCV : 87,4 fL
□ MCH : 25,2 pg
□ MCHC : 28,8 g/dL
Smear of peripheral Blood

• Erytrocytes : nomokrom
micrositiic
• Leukocytes :increase,
blast founded >20%
• Thrombocytes :Decrease
• Resume :Acute leukemia
Working Diagnosis

• Hyperleukocytsis
• Susp. Leukemia akut
Treatment

Pharmacotherapy :
• IVFD KAEN 1 B + Meylon 25 meq, 2520 ml/24 hours : 35
macro (5 kolf/day)
• Allupurinol 3x100 mg
• Transfusi PRC 2x100 cc
• Transfusi TC 2x300 cc
Plans of Examinations

• Electrolyte
• Atrial Blood Gas (ABG)
• pH urine
• Immunophenothyping
• Bone Marrow Puncture (BMP)
Prognosis

• Quo ad vitam : Dubia ad malam

• Quo ad functionam : Dubia ad malam
 08/04/18 09/04/18 10/04/18 11/04/18 11/04/18 22/03/18
Pale, headache, Pale, headache Headache, 06.00 WIB 19.30 WIB 20.00
atralgia (-), atralagia (-) atralgia,
Perdarahan gusi, Muntah darah Unconciousn Apnea
Hb: 4,9 g/dL loss of appetite berwarna ess, dyspneu
Ht:16% kehitaman, GCS: 6 -Pupil midriasis
L:448.140/µL Urinalisa: pale, fever, -suara napas(-)
T:26.000/µL Warna kuning dyspneu -suara jantung(-
jernih )
Protein (+3) Hb : 7,5 g/dL
PH: 7,0 Ht : 24,3 %
Eritrosit: 2-3/LPB Leu:
Leukosit: 4-6/LPB 232.930/µL
Sel epitel: 7- Trom: 11.000
8/LPB /µL
Bakteri (+)

Mati
-Hyperleukocytsis
batang
-Susp. Acute leukemia
otak
• Terapi lanjut • Terapi lanjut • Terapi lanjut • Suction • Informed
• IVFD KAEN 1 B + • Transfussio • Ondansentron • Pemasanga consent
bicnat 25 meq. n PRC 3x4 mg n guedel
35 makro 2x400 cc intravena • RJP 10
• PCT infus 3x300 • Transfussio siklus
mg n TC 2x300
• Allupurinol cc
3x100mg
Hiperleukositosis
• WBC : >100.000/Ul
• Complications that can occur include leukostasis
syndrome and tumor lysis syndrome
• Treatment for hyperleukocytosis include hyperhidration,
alkalinisasi and allopurinol
Leukostasis
ALL classifications base of
Immunophenotyping

•B cell
ALL
• ALL L - 1 ALL L - 2 ALL L - 3
 • Pale, weak, tired easily
Anamnesis • Fever
• Bleeding manifestasion

Physical • Anemia conjungtiva

• Splenomegali, hepatomegali
examinations • Ptekia

• Routin blood check

Supporting • Peripheral blood smear

examinations •
•
Bone marrow puncture
Imunophenotyping
Discussion
 Acute lymphoblastic leukemia is
one type of leukemia in which the
malignant proliferation of young
lymphoblast cells is indicated by
excessive amounts of lymphoblast
in the bone marrow and blood
Tehuteru 2011 : the clinical
manifestation ALL is fever, pale,
hepatomegaly, and splenomegali
Case :
-pale, fever,
hepatomegaly,splenomegaly,

Clinical manifestations of anemia is

Mialgia and atralgia caused
pale, fatigue, pale conjunctiva and
by depocit of blast cells in
laboratory examination
bone marrow that can
causing localized pain and
Case:
decreased children’s activity
-fatigue
-pale
Case:
-pale conjunctiva
-knee tenderness
-Hb: 3,4 g/dl
 Clinical manifestations of anemia is
pale, fatigue, pale conjunctiva and
laboratory examination
Hb: ∆ Hb x BB x 4
Case: Hb target: 8 g/dl
-fatigue Transfussion PRC 2x100 ml
-pale
-pale conjunctiva
-Hb: 3,4 g/dl

Trombocyte as a blood coagulation Trombocyte: 10-20 ml/KgBB/hari

Case: Transfussion TC 2x300 ml

-trombositopenia: 24.000 /UL
 Immunophenotyping was
especially useful in determining the
Gold standart for Acute diagnosis of lineage, to distinguish
Lymphoblastic Leukemia is BMP between ALL and AML

Case: Case:
-BMP (-) -conclusion of
immunophenotyping: B lineage

Treatment for Hyperleukocytosis:

Hyperhidration
Alkalinisasi
Hyperleukocytosis allopurinol
Case: Case:
-leukocyte: 495.740 /ul -IVFD KAEN 1 B+ Bicnat 25 meq 2520
cc/24 hours
-allopurinol 3x100 mg
Leukostasis occurs due to leukocytes blockage
small arteries by aggregats/ blast cell trombus
Clinical manifestation:
Brain and lung

Case:
-headache
-abdominal pain
-perdarahan gusi
THANK YOU