K. Gopakumar

Pulmonary cavitation, odontoid lytic lesion, and B symptoms: Early suspicion of the fine line between Hodgkin lymphoma and tuberculosis

To the Editor: We report the case of a 12-year-old female who complained of having neck pain after an oil massage ritual for attaining menarche. In view of persistent pain and restricted neck movements, she was evaluated with computed tomography (CT) and magnetic resonance imaging of the neck which showed erosive lesion in the odontoid process of the second cervical vertebra. There was no neurological deterioration. While the neck pain was improving with symptomatic treatment, she developed B symptoms (unexplained weight loss, unexplained fever, and drenching night sweats) and persistent cough which was not responding to antibiotics. A CT scan of the chest showed pulmonary cavitation. In view of strong clinical suspicion of tuberculosis (TB), antitubercular therapy (ATT) was started, even though Mantoux, sputummicroscopy, and cartridge-basednucleic acid amplification test forMycobacterium tuberculosiswerenegative.Her symptomsworsened despite 2 weeks of ATT and she developed lymphadenopathy and hepatosplenomegaly. In viewof a suspicionofmalignancy, shewas referred to us. In our hospital, a skeletal survey showed lytic areas in parietal bones, second cervical vertebra, sacral ala, and the right iliac blade. A CT scan showed irregular destructive areas in the odontoid process (Figure 1A). Histopathology of cervical lymph node biopsy was diagnostic of the nodular sclerosis variant of Hodgkin lymphoma (HL) (Supplementary Figure S1). A CT scan of the chest showed pulmonary soft tissue consolidations and cavitation suggestive of HL infiltrates (Figure 1B). Bone marrow was not infiltrated with malignant cells.

Spontaneous intramedullary hematoma and leukemic deposit in spinal cord causing acute onset paraplegia in a child with acute lymphoblastic leukemia

Spontaneous intramedullary hematoma/leukemic deposit in the spinal cord causing paraplegia in a child with acute lymphoblastic leukemia (ALL) is rare. We report a child with ALL, who presented with paraplegia secondary to a spontaneous spinal intramedullary hematoma at D12–L1 vertebral level and leukemic deposit in the filum terminale. Prognosis is guarded in this situation and paraplegia usually persists lifelong despite successful treatment of the disease. A 4-year-old male presented with multiple ecchymotic patches over the body, abdominal pain, melena, and hematochezia. As he had severe back pain and pain in both legs, he was very irritable and could barely move his limbs. Fundus examination in both eyes revealed small retinal hemorrhages. He had generalized lymphadenopathy and hepatosplenomegaly. On evaluation, he had a hemoglobin of 6 g/dl, total white blood cell count of 278 × 109 cells/l and a platelet count of 74×109 cells/l.His Lactatedehydrogenase (LDH) levelwas26,978U/l. His coagulation profile was normal with a PT/INR of 0.92 and aPTT of 31.6. Chest X-ray showed mediastinal widening suggestive of a mediastinal mass. Bone marrow morphology and flow cytometry was consistent with T-ALL. Treatment was initiated with steroids as per BFM ALL 95 protocol along with appropriate blood product support. On the second day of steroid therapy, he was noted to have paraplegia with a sensory and motor level at the D10 spinal cord level. He also had bowel and bladder incontinence. Contrast-enhanced computerized tomography of the brain showed intraparenchymal bleeds with perilesional edema in right cerebellum, both corona radiata, and centrum semiovale. Magnetic resonance imaging of the spine showed a T1/T2 hyperintense area in the intramedullary location of the spinal cord atD12 and L1 vertebral levels suggestive of intramedullary bleed. Another well-defined T1 isointense area and a T2 mildly hyperintense area were seen in relation to filum terminale without post contrast enhancement suggestive of leukemic deposit (Fig. 1). A cerebrospinal fluid study done on the seventh day of steroids revealed a large number of red blood cells admixed with neutrophils, lymphocytes, and monocytes. No active intervention to salvage the spinal

Risk-based management strategy and outcomes of tumor lysis syndrome in children with leukemia/lymphoma: Analysis from a resource-limited setting

Data from low‐ and middle‐income countries on tumor lysis syndrome (TLS) in the pediatric population are limited. This study aims to analyze the clinical and biochemical characteristics and treatment outcomes of TLS in children with leukemia/lymphomas in a resource‐limited setting.

Treatment of tumor lysis syndrome in children with leukemia/lymphoma in resource-limited settings—Efficacy of a fixed low-dose rasburicase

ABSTRACT Rasburicase is a novel drug used during the management of tumor lysis syndrome. In countries with limited resources, it is frequently given at a lower dose and only for the treatment of established tumor lysis syndrome and not as prophylaxis. A retrospective study was conducted in the department of pediatric oncology at a tertiary referral oncology center in south India to analyze the use of rasburicase over the past 3 years. Data of all the 18 children (< 14 years of age) who were given rasburicase for the management of hyperuricemia were collected and analyzed. With a mean rasburicase dose of 0.085 mg/kg, hyperuricemia was managed efficiently without the need for a hemodialysis in 16 children (88.8 %). The fall in mean serum uric acid levels after the administration of a single dose of rasburicase at 4, 24, and 48 hours was 31.18 %, 64.8 %, and 74.5 %, respectively. Rasburicase efficiently decreases the uric acid levels to a normal level within a short period. In resource-limited settings, rasburicase at a lower dose is a promising option for managing hyperuricemia in the event of a tumor lysis syndrome.

Wolman Disease: A Mimic of Infant Leukemia

Background: Infant leukemia most commonly present with pallor and hepatosplenomegaly. The possibility of other differential diagnosis also has to be kept in mind during evaluation, as identifying the precise etiology for this clinical presentation is crucial for management. Observation: An infant, was referred to us with suspected infant leukemia and was subsequently diagnosed to have lysosomal acid lipase deficiency/Wolman disease with a novel 5 bp deletion “c.1180_1184del” in the last exon (exon 10) of the lipase A (LIPA) gene. Conclusions: Hepatosplenomegaly and pallor resulting from nutritional deficiency or bone marrow involvement in Wolman disease can mimic infant leukemia.