Severe hypercalcemia as a form of acute lymphoblastic leukemia presentation in children

Abstract

Hypercalcemia is a rare metabolic disorder in children and is potentially fatal. It has a wide differential diagnosis, including cancer. Here, we report the case of a previously healthy 3-year-old who was admitted to the emergency room with fatigue, hyporeactivity, fever and limping gait that had evolved over 5 days and that was progressively worsening. On examination the patient was unconscious (Glasgow coma score: 8). Laboratory tests indicated severe hypercalcemia (total calcium 21.39mg/dL, ionized calcium 2.93mmol/L) and microcytic anemia. Hyperhydration was initiated, and the child was transferred to the pediatric intensive care unit. Continuous venovenous hemodiafiltration with calcium-free solution was instituted, which brought progressive normalization of serum calcium and an improved state of consciousness. Zoledronate was administered, and metabolic and infectious causes and poisoning were excluded. The bone marrow smear revealed a diagnosis of acute lymphoblastic leukemia. Hypercalcemia associated with malignancy in children is rare and occurs as a form of cancer presentation or recurrence. Continuous venovenous hemodiafiltration should be considered in situations where there is imminent risk to life.

Apresentação Atípica de Leucemia Linfoide Aguda em Criança: Relato de Caso

“…Hipercalcemia é um achado que pode aparecer em neoplasias malignas em adultos, em 5% a 20% dos casos, mesmo na ausência de metástases ósseas 11 . Já na faixa etária pediátrica, é uma manifestação muito mais incomum das neoplasias malignas, associada a apenas 0,4% a 1,3% dos casos 6 . A incidência de hipercalcemia em crianças com leucemia fica em torno de 0,6% a 4,8% 12 .…”

“…A terapêutica da hipercalcemia inclui hiper-hidratação, bifosfonatos e tratamento da doença de base. Na pediatria, bifosfonatos ainda não são muito utilizados em razão da relação com efeitos adversos à osteogênese 6 . Porém, inicialmente foram as medidas instituídas no paciente descrito.…”

“…A hipercalcemia é um achado relativamente comum nas neoplasias malignas que acometem adultos, especialmente naquelas derivadas do sistema hematopoiético, com incidência aproximada em 20% 4,5 . No entanto, a hipercalcemia associada à malignidade é um distúrbio raro na faixa pediátrica 6 . A hipercalcemia associada a lesões osteolíticas francas é uma rara complicação da LLA, e apenas alguns poucos casos com essa apresentação foram relatados 7 .…”

To: Severe hypercalcemia as a form of acute lymphoblastic leukemia presentation in children

“…Severe hypercalcemia of malignancy in children has been extensively described in the medical literature. ( 1 ) However, this complication usually presents as a late symptom of acute lymphoblastic disease and not as an early manifestation, as described in a case report by Martins et al ( 2 ) Colleti Junior et al ( 3 ) also observed that hypercalcemia was present as an early symptom of malignancy, and the serum calcium levels were higher than usual (ionic calcium: 2.95mmol/L; normal value: 1.11-1.40mmol/L). In this case, immediately after diagnosis, in addition to hydration and low doses of loop diuretic, treatment was initiated with pamidronate, a bisphosphonate, and resulted in a rapid decrease in the serum calcium levels.…”

Reply to: Severe hypercalcemia as a form of acute lymphoblastic leukemia presentation in children

“…( 3 ) In the case described, which involved severe hypercalcemia and deterioration of the state of consciousness, we opted for hyper-hydration and treatment with zoledronate and hemodiafiltration. ( 4 ) The zoledronate, rather than pamidronate, was preferred because of its greater potency and efficacy and shorter period of treatment, as previously described. ( 5 ) The decision to initiate hemodiafiltration involved the consideration that calcitonin is not marketed in Portugal and that the maximum effect of bisphosphonates is not observed before two to four days after administration.…”