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CASE REPORT

Acute Lymphoblastic Leukemia + Malnutrition(Marasmic Type) + Hyperuricemia

Presentators: Imela Sari, S.Ked

Akbar Husaini Angkat, S.Ked

Day,date: Wednesday, August 28th 2013

Supervisor: dr.Hakimi, Sp.A(K)

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Acute Lymphoblastic Leukemia, form of

leukemia, white blood cells cancer, characterized

by excess malignant, immature overproducelymphblast.

WHO estimates that 54% child mortality, 1 million

children due to malnutrition. Measurement childs

growth provide key information for malnutrition

Hyperuricemia is a level of uric acid in blood thatabnormall hi h

Background

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ObjectiveOThe aim for this study is to

explore more about the

theoritical aspects on ALL,

malnutrition, and hyperuricemia

and also to integrate theory and

application of these cases indaily life

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Epidemiology

The leukemiasmost common malignantneoplasms in childhood, about 41'% of all

malignancies that occur in children

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Acute lymphoblastic leukemia (ALL)accounts for about 77% of cases of

childhood leukemia. And the second

leading cause of death in children.

It has a striking peak incidencebetween 2-6 yr of age and occurs

more frequently in boys than in girls,

at all ag

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TREATMENT

The choice of treatment of ALL based onthe estimated clinical risk of relapse inthe patient.

Three of the most important predictivefactors : age at the time of diagnosis, the

initial leukocyte, and the speed ofresponse to treatment.

Leukocyte count < 50.000/l, agebetween 1-10 years are used to defineavera e risk.

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Criteria for high risk patieninclude:

Age < 1 ore > 10 years

WBC > 50.000/mct

T-cell phenotype

Anterior mediastinal mass

CNS disease

Translocation t (4:11) or t(9;22)

Slow response to inductio therapy

Four phase of therapy

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Chemotheraphy

InitialCNS

Intensification

Continuation

Nutritional

Supportive care Psycological aspect.

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Hyperuricemia in ALLUric acid is poorly soluble and must be

excreted continuously to avoid toxic

accumulations. Its not a specific diseasemarker so the cause of its elevation must

be detemined.

Its Elevated (>6 mg/dL in females and >7

mg/dL in males) serum [UA] may

predispose the patient to gouty attacks,

nephrolithiasis, and hypertension

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*Renal tubule excretion is greater in

children than in adults, serum level isless reliable indicator of serum uric

acid production in children,

measurement of the level in urine isrequired.

*In ALL patient its frequently caused byTumor Lysis Syndrome (TLS)

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MALNUTRITION

Th l f k f N P bl

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Theoretical framework of Nutrition Problems.

Nutrition problems

Food intake Infect Disease directcauses

Food availability Mother & child Health indirect

in household caring service causes

POOR FAMILY & EDUCATION, main

FOOD STUFF & JOB OPPORTUNITY problem

ECONOMIC & POLITIC CRISIS core

problem

Th l l f d t i t l d t t iti t t

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Three level of determinants lead to nutrition statusImmediate :Inadequacy of dietary intake

manifested :

- PEM

- Micronutr.deficiency

- Diarrhea & worm disease

- ARI

Supply & coverage immuniz

Immediate :Inadequacy of dietary intake

manifested :

-PEM

- Micronutr.deficiency

- Diarrhea & worm disease

- ARI

Supply & coverage immuniz

Underlying :- Household food security

- Access to PHC

- Community of awareness &

care for children & women

Basic :- Socio-economic conditions

(poverty & crisis)

- Political factors

- Traditional practices (infant

feeding)

- Environment & sanitation

Intervention programs

Supply side :- access : health care facilities

- supplementation of food &

micronutr.

- immunization

- quality: providersskill- information system: coverage

of suplpement., fortification,

surveillance, etc.

Demand side:- empowerment

- family awareness of nutrition

- subsidies / health insurance

Health &

Nutrition

Status of

Children

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PERMASALAHAN MEP :tmerupakan primadona masalah kesehatan gizi

t

berperan pd. morbiditas & mortalitas anakt deteksi dini dan tatalaksananya penting sebagai

upaya pencegahan melanjutnya MEP

t MEP berat perlu perawatan di intensif di RSt Berdampak jangka panjang thd. kualitas SDM

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Klasifikasi Gizi Buruk :

1. GOMEZ (195..) : BB/U

2. MacLarren (196..) : Klinis + laboratoris3. The Wellcome : Klinis + antropometris

Trust Party (1970)

4. Waterlow (1973) : BB/TB

5. WHO (1999) : Klinis + antropometris

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Klasifikasi Gizi Buruk :Wellcome classification of severe forms of protein-energymalnutrition

Percentage of

standard weight for

age

Oedema present Oedema absent

60-80 Kwashiorkor Undernourishedhment

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Klasifikasi Gizi Buruk (WHO,1999) :Gizi kurang Gizi buruk

Edema simetris -- +(oedematousmalnutrition)

BB/TB -3< Z-score

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Feature Kwashiorkor Marasmus

Growth failure Present Present

Wasting Present Present, marked

Oedema Present (mild) Absent

Hair changes Common Less common

Mental changes Very common Uncommon

Dermatosis, flaky-paint Common Does not occur

Appetite Poor Good

Anaemia Severe (sometimes) Present, less severe

Subcutaneous fat Reduced but present Absent

Face May be oedematous Drawn in, monkey-like

Fatty infiltration of liver Present Absent

Clinical Feature of Marasmus and Kwashiorkor

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CASE REPORT

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Name : ACH Age : 4 years 1 month Sex : Male Date of Admission : July, 29 th 2013

Main Complaint : Pale

History : A patient was admitted to H Adam Malik General Hospital with a

main complaint of paleness since 5 months before admittion. Thepatient had no history of nosebleed and gum bleeding, but ahistory of bruise and fever. The patient also complained abdominalbloating since 6 months ago. No family history of the samedisease. The patient had normal urination and defecation.

History of birth : Normal, assisted by a midwife, cried as soonas baby was born.

History of previous illness: Patient had been treated to MurniTeguh Hospital and BMP inspection had been done with thediagnosis was ALL

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Physical Examination

BW = 12 kg , BH = 92 cm

BW-for-Age: 75%

BH-for-Age: 90% BW-for-BH: 85%

Presens status

Sens. Compos Mentis, Body temperature:37oC, Pulse: 100 bpm, Respiratory Rate:24 bpm.

Localized status

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Localized status

Head : Face : Old man face (-), Eye : Light

reflexes(+/+), isochoric pupil, pale inferiorconjunctivae palpebrae (+/+), icteric (-/-) ,Ear : Normal appereance , Mouth : Sianosis (-),Nose: Normal appereance.

Neck : Lymph node enlargement (-)

Thorax: Symmetrical fusiformis. Epigastrialretraction(-). HR: 100 bpm, reguler, murmur(-). RR: 24x/i, reguler. Crackles (-/-)

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Abdomen: Expand. Liver palpable 4cmBAC. Peristaltic (+) normal. Spleen: SIII-

IV

Extremities: Pulse 100 bpm, regular,adequate pressure and volume, warmacral, CRT < 3. Baggy Pants (+).Decreased subcutaneous fat. Musclehypotrophy.

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Differential Diagnosis

ALL FAB L2 + Malnutrition ( Marasmic Type )+

Hyperuricemia

Working Diagnosis

ALL FAB L2 + Malnutrition ( Marasmic Type ) +

Hyperuricemia

Plans:

PRC Transfussion

Chemotherapy Urinalisis / RF

Fluid Balance

July, 29th 2013 (1st day)

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S: Pale (+) Fever (+). Bruise (+)

O: Sens: CM, Temp: 37oC, Body weight: 12kg Head