|
|
|
Indian Pediatr 2012;49: 994 |
 |
Immune Thrombocytopenic Purpura with Acute
Lymphoblastic Leukemia- An Unusual Association
|
|
Vikas Dua and JB Sharma
Action Cancer Hospital, Delhi, India.
Email: [email protected]
|
Hematologic malignancies such as
Hodgkins lymphoma, Non-Hodgkin lymphoma and chronic
lymphocytic leukemia have been associated with immune
thrombocytopenic purpura (ITP) but it is rare to see ITP in
patient with acute lymphoblastic leukemia (ALL) [1,2]. ALL
is a immunosuppressive disease and chemotherapy results in
further immunosuppressive state. Therefore, association of
autoimmune diseases with ALL is rare. Nine cases of ITP in
children with ALL have been reported so far, three of them
were acute ITP, and rest were chronic ITP [3]. Only one such
case has been reported from India [4].
A 15-year-old girl was admitted to us
with fever, increasing pallor and bleeding spots over the
body in July 2010. Physical examination revealed liver 5 cm
and spleen 3 cm below costal margin. Complete blood count
(CBC) showed hemoglobin (Hb) 6.5 g/dL, white blood cell
24000/mm 3 and
platelet 38,000/mm3.
Peripheral blood smear showed 54% blasts. The bone marrow
was consistent with pre-B ALL. Cerebrospinal fluid was
negative for malignant cells. Patient was started on
chemotherapy using BFM-95 regimen. Bone marrow aspiration
and biopsy showed remission on the 33rd
day of treatment. After phases of Protocol-I, Protocol-M,
and Protocol-II, patient was started on maintenance therapy
including 6-mercaptopurine and methotrexate. After 20 months
into therapy, the patient was noted to have a platelet count
of 59000 /mm3.
Therapy was stopped for 15 days and repeat CBC showed
platelet count of 38000/mm3,
a suspicion of relapse was kept and bone marrow aspiration
and biopsy was performed. An adequate number of
megakaryocytes with findings of ALL in remission were
detected, there was nothing suggestive of myelodysplastic
syndrome. The patient was started on prednisone at 2 mg/kg
orally daily. After 3 weeks of prednisolone, she had
improvement of her platelet count to 78000/mm3.
Her last platelet count in July 2012 was 88000/mm3.
Secondary causes of ITP were ruled out: antinuclear
antibodies was negative, double stranded DNA was 14 IU/mL,
IgG, IgA, IgM and IgE were 540,35,118 and 18mg/dL, Hepatitis
B, Hepatitis C and HIV studies were negative, and anti-phospholipid
antibodies (APLA) and direct coombs test were also
negative.
To conclude, the presence of
thrombocytopenia in patient of ALL does not always means
relapse of ALL or as a result of chemotherapy but the
possibility of ITP should also be considered.
References
1. Carey RW, McGinnis A, Jacobson BM,
Carvalho A. Idiopathic thrombocytopenic purpura complicating
chronic lymphocytic leukemia. Arch Intern Med.
1976;136:62-6.
2. Ertem M, Uysal Z, Yavuz G, Gozdašoglu
S. Immune thrombocytopenia and hemolytic anemia as a
presenting manifestation of Hodgkin disease. Pediatr Hematol
Oncol. 2000;17:181-5.
3. Horino S, Rikiishi T, Niizuma H, Abe
H, Watanabe Y, Onuma M, et al. Refractory chronic
immune thrombocytopenic purpura in a child with acute
lymphoblastic leukemia. Int J Hematol. 2009;90:483-5.
4. Yadav SP, Chinnabhandar V. Rituximab usage in
children: A double edged sword! Indian Pediatr. 2012;49:335.
|
|
|
 |
|
