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Acute hepatitis-like presentation with cholestasis of CBFB-MYH11-positive acute myeloid leukemia in an adult male: a case report. J Med Case Rep 2022; 16:294. [PMID: 35907896 PMCID: PMC9339180 DOI: 10.1186/s13256-022-03476-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Liver involvement in adults with acute myeloid leukemia is uncommon. Most of the case reports describe acute liver failure or obstructive jaundice, while acute hepatitis is rarely mentioned. We report a patient with acute myeloid leukemia who presented with clinical, biochemical, and radiological signs of acute hepatitis that totally regressed after chemotherapy. CASE PRESENTATION A 38-year-old Caucasian man presented with fever, cough, and mild fatigue. Laboratory workup showed anemia, thrombocytopenia, severe leukocytosis, transaminitis, and hyperbilirubinemia. Imaging of the abdomen (ultrasound and magnetic resonance) showed hepatomegaly, splenomegaly, upper limits portal veins diameters, increased thickness of the gallbladder wall, and significant abdominal lymph nodes. Peripheral blood smear and bone marrow evaluation were consistent with acute myeloid leukemia, and liver biopsy showed massive sinusoidal and portal infiltration by leukemic cells. After remission-inducing chemotherapy, there was complete normalization of liver function tests, and liver, spleen, and portal vein size. CONCLUSIONS This case highlights the importance of taking acute myeloid leukemia into account as a possible cause of liver damage to make a rapid diagnosis and start appropriate treatment that may lead to hematological remission and hepatic dysfunction resolution.
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Devarapalli UV, Sarma MS, Mathiyazhagan G. Gut and liver involvement in pediatric hematolymphoid malignancies. World J Gastrointest Oncol 2022; 14:587-606. [PMID: 35321282 PMCID: PMC8919016 DOI: 10.4251/wjgo.v14.i3.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/22/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
Hematolymphoid malignancies are common neoplasms in childhood. The involvement of the gastrointestinal (GI) tract, liver, biliary system, pancreas, and peritoneum are closely interlinked and commonly encountered. In leukemias, lymphomas, and Langerhans cell histiocytosis (LCH), the manifestations result from infiltration, compression, overwhelmed immune system, and chemotherapy-induced drug toxicities. In acute leukemias, major manifestations are infiltrative hepatitis, drug induced gastritis, neutropenic typhlitis and chemotherapy related pancreatitis. Chronic leukemias are rare. Additional presentation in lymphomas is cholestasis due to infiltration or biliary obstruction by lymph nodal masses. Presence of ascites needs a thorough workup for the underlying pathophysiology that may modify the therapy and affect the outcome. Uncommon hematolymphoid malignancies are primary hepatic, hepatosplenic, and GI lymphomas which have strict definitions. In advanced diseases with extensive spread, it may be impossible to distinguish these diseases from the primary site of origin. LCH produces biliary strictures that mimic as sclerosing cholangitis. Liver infiltration is associated with poor liver recovery even after chemotherapy. The heterogeneity of gut and liver manifestations in hematolymphoid malignancies has a clinical impact on their management. Though chemotherapy is the mainstay of therapy in all hematolymphoid malignancies, debulking surgery and radiotherapy have an adjuvant role in specific clinical scenarios. Rare situations presenting as liver failure or end-stage liver disease require liver transplantation. At their initial presentation to a primary care physician, given the ambiguity in clinical manifestations and the prognostic difference with time-bound management, it is vital to recognize them early for optimal outcomes. Pooled data from robust registries across the world is required for better understanding of these complications.
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Affiliation(s)
- Umeshreddy V Devarapalli
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Moinak S Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Gopinathan Mathiyazhagan
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Sandart A, Harila-Saari A, Arnell H, Fischler B, Vakkila J. Pattern and Prevalence of Liver Involvement in Pediatric Acute Lymphoblastic and Myeloid Leukemia at Diagnosis. J Pediatr Gastroenterol Nutr 2021; 73:630-635. [PMID: 34292217 DOI: 10.1097/mpg.0000000000003243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The prevalence and significance of liver involvement at diagnosis was studied in pediatric acute lymphoblastic (ALL) and myeloid leukemia (AML). METHODS A population based cohort of 122 pre B-ALL, 22 T-ALL and 45 AML patients was formed from the Nordic Society of Pediatric Hematology and Oncology leukemia registries (years 2005-2017). Hepatomegaly, elevated alanine aminotransferase, high INR, hypoalbuminemia and conjugated hyperbilirubinemia at diagnosis were used as markers for liver involvement. Minimal residual disease (MRD), time to relapse and overall survival (OS) were correlated with liver involvements. RESULTS The pattern of liver involvement was significantly different between leukemia subtypes (P = 0.025). The proportion of patients without liver abnormalities was 50.0% in AML and 44.8% in pre B-ALL and 23.5% in T-ALL patients. Hepatomegaly characterized lymphatic leukemia being present in 41.8% and 58.8% of pre B- and T-ALL patients. Liver dysfunction was most common in AML (29.5%) and least frequent in pre B-ALL (7.4%,) (P = 0.001). Conjugated hyperbilirubinemia was present in less than 5% of patients. Hepatomegaly correlated positively with age in pre B-ALL (P = 0.036) and white blood cell count (WBC) in AML (P = 0.010). Hepatic dysfunction was related with high WBC in pre B-ALL (P = 0.037) and AML (P = 0.001). Liver involvement in patients with ALL was not associated with toxicity or outcome. Patients with AML without liver involvement demonstrated superior OS. CONCLUSIONS Liver involvement is frequent at diagnosis in pediatric leukemia and its prevalence is related with leukemia subtype, age and WBC. In AML, but not in ALL, it associates with suboptimal prognosis.
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Affiliation(s)
- Amelie Sandart
- Department of Pediatrics, Karolinska University Hospital, Stockholm
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala
| | - Henrik Arnell
- Department of Pediatrics, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm
| | - Björn Fischler
- Department of Pediatrics, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm
| | - Jukka Vakkila
- Department of Pediatrics, University of Helsinki, Helsinki, Finland
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Raja RA, Wolthers BO, Frandsen TL, Albertsen BK, Schulz N, Damholt MB, Schmiegelow K, Jørgensen MH. Acute liver failure in a four-year old girl during maintenance therapy of acute lymphoblastic leukemia. Pediatr Hematol Oncol 2021; 38:669-675. [PMID: 33798035 DOI: 10.1080/08880018.2021.1906800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- R A Raja
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B O Wolthers
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - T L Frandsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B K Albertsen
- Children and Adolescent Health, Aarhus University Hospital, Aarhus, Denmark
| | - N Schulz
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - M B Damholt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - K Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - M H Jørgensen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Denton CC, Rawlins YA, Oberley MJ, Bhojwani D, Orgel E. Predictors of hepatotoxicity and pancreatitis in children and adolescents with acute lymphoblastic leukemia treated according to contemporary regimens. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26891. [PMID: 29218844 PMCID: PMC7522002 DOI: 10.1002/pbc.26891] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/12/2017] [Accepted: 10/14/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatotoxicity and pancreatitis are common treatment-related toxicities (TRTs) during contemporary treatment regimens for acute lymphoblastic leukemia (ALL). Limited detailed data from Children's Oncology Group (COG) regimens has been previously reported to enable identification of patient and treatment risk factors for these toxicities and their impact on outcomes. PROCEDURE We analyzed a retrospective pediatric ALL cohort treated at a single institution according to COG regimens from 2008 to 2015. The primary endpoint was cumulative incidence of study-defined "severe" hepatotoxicity (Common Terminology Criteria for Adverse Events [CTCAE] Grade ≥ 4 transaminitis or Grade ≥ 3 hyperbilirubinemia) and clinically significant pancreatitis (any grade). Pancreatitis was additionally classified using the Ponte di Legno (PdL) toxicity criteria. Secondary endpoints were chemotherapy interruptions, early disease response (end of induction [EOI] minimal residual disease [MRD]), and event-free survival (EFS). RESULTS We identified 262 patients, of whom 71 (27%) and 28 (11%) developed hepatotoxicity and pancreatitis, respectively. Three cases of pancreatitis did not fulfill PdL criteria despite otherwise consistent presentations. Both TRTs occurred throughout therapy, but approximately 25% of hepatotoxicity (18/71) and pancreatitis (8/28) occurred during induction alone. Both obesity and age (≥10 years) were identified as predictors of hepatotoxicity (subdistribution hazard ratio [SHR] obesity = 1.75, 95% confidence interval [95% CI] 1.04-2.96; SHR age ≥10 = 1.9, 95% CI 1.19-3.10) and pancreatitis (SHR obesity = 2.18, 95% CI 1.01-4.67; SHR age ≥ 10 = 2.76, 95% CI 1.19-6.39, P = 0.018). Dose interruptions were common but neither toxicity influenced EOI MRD nor EFS. CONCLUSIONS Obese and/or older children are particularly at risk for hepatotoxicity and pancreatitis, and may benefit from toxicity surveillance and chemoprotective strategies to prevent or mitigate associated morbidity.
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Affiliation(s)
- Christopher C. Denton
- Division of Hematology, Oncology, & BMT, Children’s Hospital Los Angeles, Los Angeles, California
| | - Yasmin A. Rawlins
- College of Physicians and Surgeons, Columbia University, New York, New York
| | - Matthew J. Oberley
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Deepa Bhojwani
- Division of Hematology, Oncology, & BMT, Children’s Hospital Los Angeles, Los Angeles, California,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Etan Orgel
- Division of Hematology, Oncology, & BMT, Children’s Hospital Los Angeles, Los Angeles, California,Keck School of Medicine, University of Southern California, Los Angeles, California
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Kueht ML, Cotton RT, Godfrey EL, Dreyer ZE, Fishman DS, Goss JA. Deliberate liver transplantation for fulminant liver failure with acute lymphoblastic leukemia. Liver Transpl 2016; 22:1724-1726. [PMID: 27597163 DOI: 10.1002/lt.24627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 08/19/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Michael L Kueht
- Division of Abdominal Transplantation Michael E. DeBakey Department of Surgery Baylor College of Medicine, Houston, TX
| | - Ronald T Cotton
- Division of Abdominal Transplantation Michael E. DeBakey Department of Surgery Baylor College of Medicine, Houston, TX
| | - Elizabeth L Godfrey
- Division of Abdominal Transplantation Michael E. DeBakey Department of Surgery Baylor College of Medicine, Houston, TX
| | | | - Douglas S Fishman
- Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation Michael E. DeBakey Department of Surgery Baylor College of Medicine, Houston, TX
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Abstract
A diagnosis of acute lymphoblastic or myeloblastic leukemia was made in 6 children ages 4 to 14 years who presented with a clinicobiochemical picture of acute hepatitis without liver failure. Standard chemotherapy, including 1 week pretreatment with steroids in children with lymphoblastic leukemia, allowed complete remission of the leukemia and normalization of serum liver tests.
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