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A Clinical and Laboratory Study on Infection in Childhood Leukemia.

Journal of the Korean Pediatric Society 1986;29(7):699-709.
Published online July 31, 1986.
A Clinical and Laboratory Study on Infection in Childhood Leukemia.
Jung Hee Lee, Kwang Hyun Kim, In Joon Seol, Heung Jae Lee, Hahng Lee, Chong Moo Park
Department of Pediatics,College of Medicine, Hanyang University Hospial, Seoul, Korea
소아백혈병 환아의 감염증에 관한 임상적 고찰
이정희, 김광현, 설인준, 이홍재, 이 항, 박종무
한양대학교 의과대학 소아과학교실
Acute Leukemia is the most common among malignant disease in childhood, and the loss of normal hematopoiesis by proliferation of leukemic cells and the chemotherapy result in immunosuppression and the reduction of red blood cells, normal white blood cells and platelets. The children with acute leukemia may succumb to the disease due to infections, hemorrhage, other complications, or the progression of the malignant process. Infection is now the major complication most frequently confronted during the course of the disease, and, along with hemorrhage, infection is also the most common cause of death in these immunosuppressed children. Proper diagnosis and appropriate treatment of each infectious episode would be most important in deciding the survival or, the ultimate outcome of the basic disease. Clinical manifestations of infection in the leukemic patient may be nonspecific and difficult to evaluate with the regard to the etiology, and yet febrile episodes occur frequently with infections. Therefore, infection should be the first to be considered as the cause of fever, unless other basis for fever could be clearly defined, and aggressive investagation and treatment should be provided for each febrile episode. However, febrile episodes often occur from the malignant process itself, or from other noninfectious causes such as chemotherapy and transfusion. A clinical and laboratory study was carried out on the febrile episodes with the body temperature over 38.5° C among 37 children with acute leukemia, diagnosed and treated at the Hanyang University Hospital during the period of one year from May, 1984 through April, 1985. The summary of the results from the study and the observation is as follows: 1) The sex distribution of the 37 study patients showed slight male preponderance: 14 male patients, and 9 female patients for acute lymphocytic leukemia (ALL); 8 male, and 6 female for acute nonlymphocytic leukemia(ANLL). The age distribution at the time of initial diagnosis of acute leukemia showed 24 patients(64.9%) for the age group of 2 to 10 years: 4 patients(10.8%) for the age 0 to 2 years: 10 patients(27.0%) for the age 2 to 5 year: 14 patients(37.7%) for the age 5 to 10 years: 9 patients(24.3%) for the age 10 to 15years (Table 1). 2) Total 78 febrile episodes were observed over the study period of one year among the 37 study patients. As for the clinical types of infections for these febrile episodes, 35 episodes were for respiratory tract infection, 13 for sepsis, 12 for urinary tract infection, 5for gastrointestinal infection, 8 for other bacterial infection, and 2 for varicella were observed during the study period. However, no definite evidence of infection could be determined in 15 febrile episodes (Table 2, 4) 3)The frequency distribution of infectious episodes for each phase of the antileukemic therapy over the study period showed the highest frequency rate in the leukemic relapse phase for ALL wtih an average of 2.0 episodes per patient, and in the consolidation phase for ANLL with an average of 2.17 episodes per patietns.(Ikble 3). 4) The frequency distribution of infectious episodes according to the absolute granulocyte count(AGN) showed 44 episodes (55.1%) for the patients with AGN below 1,000/mm3, indiacting the highest risk for infection with severe neutropenia or low AGN. However, 23episodes (29.4%) occurred for the patients with AGN above 2,000/mm3(,Ikble 4, Fig. 1-a). 5) Among the 5 patients who expired of sepses, the infectious organisms proved to be Gram-negative bacteriae with pseudemonas aeruginosa,Enterobacter cloacae, and Klebsilella pneumoniae. In one patient, fungal septicemia with Saccharmyces cerviciae was identified. 3 patients who died of sepses showd AGN below 1,000/mm3 at the initial phase of final septic episodes, and all 5 patients had AGN bslow 1,000/mm3 at the the of death (Table 5,6). 6) In conclusion, infection occurs in high frequency during the course of childhood leukemia, and becomes the most frequent cause of death for these immunosuppressed children, regardless of the therapeutic response to the antileukemic therapy. The correlation of febrile episodes to the presence of infection is deary significant, and, to reduce the overall mortality rate, accurate diagnosis and prompt appropriate management of infection would be imperative in dealing with each febrile episode. The clinical pattern of the infections among the febrile episodes observed in this study is considered to be helpful in the future management of these frequent infectious complications. Life threatening infections during the greatment of childhood leukemia occur with high frequency in the neutropenic state. The causative organisms often are Gram-negative, such as Pseudemonas aeruginosa, or opportunistic, not commonly seen in the individuals with intact immune state. These specific pattern deserve much attention in establishing the effective treatment of childhood leukemia.
Key Words: Acute leukemia, Infection.

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