A challenging case of an adolescent and young adult patient with high-risk acute lymphoblastic leukemia: the need for a multidisciplinary approach: a case report

Abstract

Background Adolescents and young adults diagnosed with acute lymphoblastic leukemia are treated according to pediatric-based regimens to achieve better results. However, implementation of intensive chemotherapy protocols in this age group is associated with increased treatment-related toxicities, affecting almost every organ and system. In this case, the focus of our interest was on rather rare entities: steroid-induced psychosis that seldom develops in children and adolescents, and choroid plexus hemosiderosis, infrequently identified as a first sign of iron overload. Case presentation The aim of this paper is to present a challenging case of a 15-year-old Caucasian male patient treated for high-risk acute lymphoblastic leukemia and who experienced various adverse incidents during intensive chemotherapy, thus necessitating a high-quality multidisciplinary approach. Slow minimal residual disease clearance was an additional concerning issue. Induction and re-induction were complicated by steroid-induced hyperglycemia that required multiple-week insulin. During consolidation, acute kidney injury on the basis of chronic kidney disease was verified, demanding subsequent drug dose modifications. By the end of re-induction, after dexamethasone cessation, infrequent steroid-induced psychosis, presented as incoherent speech, aggressive behavior, and mood swings, required intensive psychiatric support. Neurological evaluation of seizures revealed uncommon choroid plexus hemosiderosis by brain magnetic resonance imaging, warranting appropriate selection of iron chelation therapy in the context of preexisting nephropathy. Ultimately, iron deposits of moderate intensity were verified by liver magnetic resonance imaging, while heart tissue remained intact. The early diagnosis and adequate treatment of aforementioned difficult toxicities resulted in complete recovery of the patient. Conclusions Treating adolescents with high-risk acute leukemia and multiple therapy-related morbidities remains a challenge, even in the era of extensive and effective supportive therapy. Superior survival rates might be achieved by prompt recognition of both frequent and rarely encountered adverse episodes, as well as well-timed and appropriate management by a well-coordinated multidisciplinary team.

Measuring neurobehavioral side effects of corticosteroids in pediatric acute lymphoblastic leukemia: A scoping review

“…Ultimately, 24 studies met the eligibility criteria and were included in the review. 13,15,16,[20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] The current review revealed a variety of measures used to assess neurobehavioral side effects in the pediatric population undergoing corticosteroid treatment. Among the different methods of measurement identified in the included articles, clinical assessment and description was the most commonly used, utilized in seven articles.…”

“…Among the different methods of measurement identified in the included articles, clinical assessment and description was the most commonly used, utilized in seven articles. 15,16,30,[35][36][37][38] Sleep was evaluated by a combination of formalized measures, 13,20,29 actinography, 20,[24][25][26]32 sleep diaries, 21,25 and wearable technology (Micromini Motionlogger Sleep Watch). 24 Of the 12 validated scales identified (Table 1), the Pediatric Qualityof-Life Inventory (PedsQL) was most frequently used, utilized in four articles.…”

“…Full‐text assessment for eligibility was conducted on the remaining 71 studies. Ultimately, 24 studies met the eligibility criteria and were included in the review 13,15,16,20–39 …”

“…The current review revealed a variety of measures used to assess neurobehavioral side effects in the pediatric population undergoing corticosteroid treatment. Among the different methods of measurement identified in the included articles, clinical assessment and description was the most commonly used, utilized in seven articles 15,16,30,35–38 . Sleep was evaluated by a combination of formalized measures, 13,20,29 actinography, 20,24–26,32 sleep diaries, 21,25 and wearable technology (Micromini Motionlogger Sleep Watch) 24 …”