Coexistence of Life Threatening Chemotherapy Related Leukoencephalopathy, Saggital Sinus Thrombosis and Multiple Organ Failure in a Child with Acute Lymphoblastic Leukemia: An Unusual Case with Clinical Recovery

Abstract

A nine-year old girl with T cell acute lymphoblastic leukemia (ALL) had acute severe neurologic complications at the end of the remission-induction chemotherapy course. Thirty-six hours following triple intrathecal (IT) therapy and intravenous (IV) administration of L-asparaginase (L-asp), tetraplegia developed and she became unconscious. She had bouts of hypertension and persistent tachycardia unresponsive to digitalis therapy. Magnetic resonance imaging (MRI) showed multiple brain white matter hyperintensities and filling defects in the saggital sinus, suggesting thrombosis. Over the 40 days, in addition to her neurologic compromise she also had transient diabetes mellitus, severe hyperlipidemia, hypoproteinemia and edema, liver and heart failure and staphylococcus aureus sepsis with prolonged bone marrow depression. Despite, coexistence of all these chemotherapy related complications, her neurologic functions and multiple organ failure improved gradually. After a 70 days' period of interruption, chemotherapy was resumed and continued without any further complications. Although, the etiology of her extensive sensitivity to some drugs remains unclear, we believe that it is important to document these unusual events in this child.

L-Asparaginase-induced Posterior Reversible Encephalopathy Syndrome during Acute Lymphoblastic Leukemia Treatment in Children

“…L -Asparaginase is used in induction chemotherapy of ALL; it is known to cause superior sagittal sinus thrombosis with or without infarction, less frequently cerebral arterial thrombosis, systemic thrombosis and intracerebral hemorrhage in a small percentage of patients [9,29] . The mechanism of hemorrhage and thrombosis is related to the depletion in plasma proteins involved in blood coagulation and fi brinolysis.…”