Leukemia Clues

Leukemia CluesMany of the PedEM Morsels accentuate the need to be vigilant, although reasonable, and guard against the significant pathology that may present in a benign manner. Often this merely requires maintaining an “active” mind when evaluating children.  The “active” mind searches for clues for possible Kawasaki Disease when evaluating the child with prolonged fever.  Vigilance allows us to actively ponder HUS when evaluating the patient with diarrhea.  Vigilance, however, requires knowledge about the subtle clues that we need to actively search for.  Let us, then, review some of the subtle clues that may raise your suspicion for one of the more alarming diseases: Leukemia.

 

Leukemia: Basics

  • Cancer is the #1 cause of death due to disease in developed countries.
  • Few known risk factors for childhood cancer  [American Cancer Society]
    • Children are more sensitive to ionization radiation, but the actual number of resultant cases is unknown.
    • Small percentage attributed to inherited genetic mutations.
    • Certain syndromes are associated with increased risk for cancer. (ex, Down Syndrome)
  • Leukemia is the most common childhood malignancy
    • Accounts for ~30% of all childhood cancers
    • Acute lymphocytic leukemia (ALL) does occur in adults, but 75% of cases are in patients 0-19 years of age.
    • Leukemia, can also occur in neonates. (See Neonatal Leukemia)

 

Leukemia: Presentation

  • Recent meta-analysis looked at clinical presentation of childhood leukemia. [Clarke, 2016]
    • Worth a gander.
    • Advocates for reasonable vigilance using focused History and Physical Exam (novel concept).
  • The early presentation is often with non-specific symptoms.
    • Similar to the multitude of other self-limiting illnesses – makes it easy to miss.
    • Pallor, Fever, and Fatigue are commonly encountered
      • Also common in many other conditions
      • These should cause us to actively look for other findings / symptoms
  • Look for clues, even if non-specific:
    • At diagnosis, 5 features were present in >50% of cases: [Clarke, 2016]
      • Hepatomegaly (64%)
      • Splenomegaly (61%)
      • Pallor (54%)
      • Fever (53%)
      • Bruising (52%)
    • In 33% – 50% of cases, 8 additional features were prominent: [Clarke, 2016]
      • Recurrent Infections (49%)
      • Fatigue (46%)
      • Limb pain (43%)
      • Hepatosplenomegaly (42%)
      • Bruising/petechiae (42%)
      • Lymphadenopathy (41%)
      • Bleeding tendency (38%)
      • Rash (35%)
    • Abdominal symptoms (ex, anorexia, weight loss, pain, and distention) are also common.
  • One clue may not require investigation, but one clue leading to the discovery of another… and another… well, that’s how you build a case.

 

Leukemia: Remain Vigilant

  • Fortunately, leukemia is relatively rare, and hopefully your patient will not have it, but…
  • Our vigilance today makes a difference tomorrow.
  • Vigilance does not cost a lot of money.
    • Perform a thoughtful history – “Did I ask about unexplained bleeding from the gums?”
    • Be actively looking for clues during your exam – and specifically document the presence of lack of hepatomegaly, splenomegaly, lymphadenopathy, and/or pallor.

 

References

Clarke RT1, Van den Bruel A1, Bankhead C1, Mitchell CD2, Phillips B3, Thompson MJ4. Clinical presentation of childhood leukaemia: a systematic review and meta-analysis. Arch Dis Child. 2016 Oct;101(10):894-901. PMID: 27647842. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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