Battle of Odds - Acute Leukemia

A thirteen year old girl desperately wanted to get better and go home. “As soon as possible, doc” were her exact words. We too wanted that. Of course, we were being unrealistic; our judgments clouded by emotions. The deep icterus (yellow tinge) to her eyes, skin and nails defied the possibility. The persisting backache which she claimed was getting better (we seriously doubted it) also indicated the graveness of her condition. She wanted to walk around and see the world. 

Then, we were posted in hemato-oncology and there was this little girl who was in adult hematology. She had just turned thirteen and no longer qualified as a pediatric age group (according to the hospital policy). We had to take her over from the pediatricians. We were worried because we were taking charge of a very sick patient from another department. A single critical patient meant immense responsibility. The pediatric resident was casual with the handover with his ultra brief history and updates on the patient. And we were not complaining as we knew until and unless we studied the case ourselves, we wouldn’t know what was going on with her system. 

Her liver and spleen were immensely enlarged. She was severely anemic, and thrombocytopenic (below normal platelet count, making one prone to bleeding). The bleakness was probably obvious on our faces as she asked us what was wrong with her. We said she had problems with her blood and there were deficiencies that needed to be investigated, a highly tangential statement.

So as routine protocol her baseline investigations were sent and we did a bone marrow examination on her and she came out to be a case of Acute Lymphoblastic Leukemia- ALL (a type of leukemia- myeloid and lymphoblastic). As usual we needed to tell the parents. They were expecting something similar. We had already primed them for the worst. The expression on the mother’s face was a mixture of emotions. Expectant, as she knew her child was very sick. Hate, as we were telling that her only child was terminal. Helplessness, as she had no other option left.  She gathered herself, reminding us how she overcame her own struggle with the carcinoma in her breast. 

But there was the famous million dollar question- what to do next? We needed to know her prognosis, the genetic pattern and the multisystem involvement to find the survival benefit. The liver and spleen were already involved. Bone marrow too showed infiltration with malignant cells. Now what we needed to find out was her neural involvement. 

We immediately started her on BMF protocol chemotherapy for acute lymphoblastic leukemia. We were content. At least we were doing something to the disease. Unfortunately, she started developing post chemotherapy complications. She was persistently nauseous. There was no oral intake for an entire 48 hours as she vomited. We shifted her to intravenous medications and cancelled everything that could induce nausea. For the next 72 hours she was hungry, which was a good sign and the parents were happy to get something for their child to eat after four days.  

She needed to undergo lumbar puncture immediately for intrathecal dose of methotrexate (given with a needle in to the spine) as a part of her pre-induction regime. She had previous history of back pain and disc involvement which was skeptical in itself so we had to be extra careful with her dosage. Another pressing problem was that she had thrombocytopenia and we were unable to bring it up despite multiple random donors as well as single donor platelet transfusions. As her condition was deteriorating we needed to complete her first cycle of chemotherapy as soon as possible. So we decided we should go ahead with the chemo including the pre-induction and the lumbar puncture. 

Complications followed. She developed acute back pain as previously and went into paraplegia (complete inability to move both of the lower limbs) after 72 hours. An immediate MRI of the spine showed a post lumbar puncture internal bleed. The pre-existing internal spinal bleed along with infiltration of the whole spine with the malignancy was obvious.

By the end of the seventh day we were back to square one. We were left with a very young patient of acute lymphoblastic leukemia with poor prognosis and paraplegia. 

The terminal event for her was the bleeding, the chance of which was always there with her low platelet count. She had epistaxis (nose bleed), hematuria (blood in urine), petechae (skin bleed), and an oral bleed. We were never able to get her platelets above 10,000 (safe range is above 20,000 normal range is 1.5 to 4.5 lac). 

The struggle ended on the 9th day.

The questions that were circling our mind were- Why did we keep her hopes so high?  She was too young to know the reality and we needed her to believe to fight. Why did we continue the chemo? 

It was probably her only option for going home early, if at all that was on the cards. 

Why did we try the hardest? 

We needed to defy routine. We needed to believe in something for her sake. We needed to take a positive step even if it only meant a five percent chance of survival. We felt sorry for her. We pitied ourselves for the human limitation.We were sorry for the advances. So much energy into research, yet we can never work miracles. 

But not all the battles are lost. 

Quite often we meet hematology follow-ups who have defied the disease. They happily greet us in outpatient care and are enthusiastic about telling us their exciting progress on the chemotherapy regime. The progress has made them wise. They understand themselves and their disease more than we as physicians do. 

Irrespective of the prognosis and the prospective, hopes are definitely high.