Alarm Symptoms of

Hematoonco in Pediatrics
dr. Cece Alfalah, M.Biomed, Sp.A (K) DHANY FEBRIANTARA
Pediatric Hematology and Oncology
Fever (febrile neutropenia)
 T ≥ 38.3°C or T ≥ 38.0°C sustained for >1 h or occurs twice within
24h periode
 ANC < 500/uL or ANC <1000/uL expected decrease 500/uL over
48 h
 Severe neutropenia, prolonged neutropenia are highest risk for
the development of septicemia and opportunistic infection
 Broad-spectrum antimicrobials should be instituated within 30
min and receiving steroid therapy
Muscle bleeds
 Bruises and soft tissue bleeding
 Iliopsoas muscle bleeds
 Thigh muscle bleeds
 Neck swelling
 Muscle bleeds in the upper or lower arms
 Gluteus muscle bleeds
 Neck swelling: EMERGENCY !!
Potential airway obstruction
Bruises & soft tissue bleeding:
 Rare severe pain
 No malfunction
 No coagulation factor examination
Muscle bleeds in the upper or lower arm:
Be carefully of sign compartment syndrome

Iliopsoas muscle bleeds:

Cannot be straightened of leg/flexion of
pelvis joints
Gluteus muscle bleeds:
 Pain
Thigh muscle bleeds  Swelling
 Pain  Impaired mobility
 Impaired mobility
 Be carefully of sign
compartment syndrome

Wulff , Zappa, Womack. Emergency care for patients with hemophilia.3rd ed. 2010
.
Joint bleeds (hemarthrosis)
 Early onset hemarthrosis
 Advanced hemarthrosis
Advanced hemarthrosis : Gunakan alat bantu/crutches
 Sweeling, pain
 Palpation: warmer than surrounding
area
 Joints cannot be moved

Early onset hemarthrosis :

 Initial sensation/aura
 Sweeling, pain Fingers & toes can also experience
 Limited joints movement hemarthrosis

Wulff , Zappa, Womack. Emergency care for patients with hemophilia.3rd ed. 2010
Bleeding manifestations of immunie
thrombocytopenia (ITP)
 Mild bleeding of bruising and petechiae
 Rare of Intracranial hemorrhage with bleeding in the skin
followed by epistaxis

Neunert CE, Buchanan GR, Imbach P, Bolton P, Bennett C, Neufeld E, et al. Blood. 2013
Malignancies of the central nervous
systems
 CNS lesions risk for rapid deterioration as a result of increased
intracranial pressure (ICP)
 Headache (97%) is the most common presenting complaint
 Limitation in eye movement, visual field defects, seizures, and
gait disturbance
 CT Scan and MRI preferred test to evaluate brain structure
Neurologic emergencies
 Seizures
 Alterations in mental status
 Cerebrovascular accident (CVA)
 Spinal cord compression (SCC)
 Increased ICP
Differential diagnosis
 Seizures: CNS tumors, intrathecal chemotherapy, metabolic
derangements
 Raised ICP : CNS tumors, shunt obstruction, pseudotumor
cerebri, infection
 CVA: Asparginase, hyperleukocytosis, coagulopathy/hemorrhage
 Alterations in mental status: CNS tumor, opiates,
benzodiazepines, steroids, high dose cytarabine or
methotrexate, ifosfamide, nelarabine, metabolic derangnement
Spinal cord compression
 Occurs in approcimately 3-5% of all pediatric oncology patients
 Lead to irreversible neurologic damage, including permanent paralysis
(lower limb paralysis)
 Presenting with back pain (80%) and changes in bowel or bladder habits
 If suspected, dexamethason with a loading dose 1-2 mg/kg IV, followed
0.25-0.5 mg/kg every 6 h
 Definitive therapeutic include surgical resection, radiation, and
chemotherapy
Chemotherapy side effect
Nausea

Severe vomiting

Cyclophosphamide >> doxorubicin/daunorubicin

Lebaron S, Zelzer LK, Lebaron C, Scott SE, Zetzer PM. Medical and Pediatric Oncology. 1988;16:263-8
Ruggiero A, Rizzo D, Catalano M, Coccia P, Triarico S, Attina G. J International Med Research. 2018
Anaphylaxis and hypersensitivity to
chemotherapeutic agents
Etiology Presentation
 Asparaginase  Bronchospasm
 Platinum agents  Dyspnea
 Etoposide  Wheezing
 Monoclonal antibodies  Angioedema
 Flushing
 Nausea
 Rhinitis
 Pruritus
 Urticaria
 Hypotension
Superior vena cava syndrome and
superior mediastinal syndrome
 Superior vena cava syndrome (SVCS) consist of the signs and
symptoms of superior vena cava obstruction due to compression
or thrombosis
 Superior mediastinal syndrome (SMS) consist of SVCS with tracheal
compression
 Etiology
 Intrinsic causes: vascular thrombosis
 Extrinsic causes: malignant anterior mediastinal tumors (hodgkin lymphoma,
non-hodgkin lymphoma, teratoma, thyroid cancer, thymoma)
Respiratory emergencies (SVCS/SMS)
Airway compromise CNS Venous obstruction
 Cough (54%)  Syncope (10%)  Facial swelling, edema (82%)
 Dyspnea (54%)  Headache (9%)  Engorged chest wall vessels
 Hoarseness (17%)  Confusion (4%) (53%)
 Stridor (4%)  Lethargy (2%)  Arm edema (42%)
 Tachypnea  Blurry vision (2%)  Cyanosis of face, neck, & upper
 Orthopnea  Papiledema extremieties
 Wheezing  Ear fullness  Petechiae
 Anxiety  Pleural effusion

Seth & Bhat. In J Pediatr, 2011

Renal emergencies
Oliguria/anuria
 Prerenal: septic shock, dehdration, diarrhea, metabolic abnormalities from
tumor lysis
 Postrenal: hemorrhagic cystitis, abdominopelvic tumors
 Renal insufficiency : chemotherapy agents, contrast dyes, anti-infectives

Hypertension
Symptoms may include headache, irritability, lethargy, confusion, and if
untreated, seizure
Hyperleukocytosis
Total white cell count >100.000/mm³
 9-13% of children with acute lymphocytic leukemia (ALL)
 5-22% of children with acute myeloid leukemia (AML)
 Differentiated from leukemoid reaction
 >50.000/mm³
 Certain infection, including pertusis, staphylococcus aures, pneumoccus, tuberculosis
Clinical features
 Central nervous system (CNS): blurred vision, confusion, somnolence, delirium,
stupor, coma and papilledema
 Pulmonary: tachypnea, dsypnea, hypoxia
 Genitourinary: oliguria, anuria, rarely priapism
 Vascular symptoms: DIC, retinal hemorrhage, myocardial infarction, and renal
vein thrombosis
Tumor lysis syndrome (TLS)
TLS arises due to the rapid release of intracellular metabolites from dying tumor
cells in quantities that exceed the excretory capacity of the kidneys
May result in the following metabolic complications:
 Hyperuricemia
 Hyperkalemia
 Hyperphosphatemia
 Hypocalcemia
 Renal insufficinency/failure
Diagnostic criteria for laboratory TLS
The present of two or more abnormal serum values at presentation
 Uric acid ≥ 8 mg/dl
 Potassium ≥ 6 mg.Dl
Dying Tumor Cells
 Phosphate ≥ 2.1 mmol/l
 Calcium ≤ 1.75 mmol/l
 Creatinine > normal
↑ PO42- ↑ K+ ↑ Lactate ↑ Urate ↓ Ca2+
THANK YOU