Acute Lymphoblastic Leukemia with Malignant Hypercalcemia: A Case Report

Abstract

Patient: Female, 6 Final Diagnosis: Acute lymphoblastic leukemia Symptoms: Abdominal pain • bloody diarrhea • malaise • vomiting Medication: — Clinical Procedure: Chemotherapy Specialty: Oncology Objective: Unusual clinical course Background: Malignant hypercalcemia is a rare finding in the pediatric population, even more rare in hematological malignancies, such as leukemia. Case Report: We present a case of a 6-year-old female patient who was diagnosed with acute lymphoblastic leukemia, with secondary hypercalcemia. She started chemotherapy following the IC-BFM ALL2002 protocol with simultaneous calcitonin, diuretics and aggressive hydration for hypercalcemia, and went into complete remission after the induction therapy. After 4 months of chemotherapy, she was diagnosed with relapse associated again with malignant hypercalcemia, and underwent chemotherapy with the relapse protocol. There was no response after the first 2 cycles, so we decided to start her on clofarabine. Due to the severe hypercalcemia and consecutive osteolysis, she developed several bone fractures and needed gypsum immobilization. We started her again on calcitonin, but she developed severe adverse reactions, so we found it necessary to start bisphosphonates, first zoledronic acid intravenously, and afterwards clodronate orally. Consolidation of bone fractures was achieved, but due to prolonged immobilization she developed bedsores, superinfected with Lichtheimia corymbifera . We started posaconazole orally, but she rapidly went into severe sepsis with multiple organ failure. The leukemia showed no response to chemotherapy, progressed rapidly, and the patient died. Conclusions: Malignant hypercalcemia is associated with a poor prognosis in leukemia, and might need a more aggressive therapy.

Malignant hypercalcemia as the debut of acute lymphoblastic leukemia in a pediatric patient—a diagnostic and therapeutic approach: Case report

“…Further case reports and studies in children were later recorded, including a study conducted in the United Kingdom between 2003 and 2014 that showed that although hypercalcemia can occur in any type of cancer, it was more common in children with leukemia ( 8 ). Other studies have shown the association of malignant hypercalcemia with precursor phenotype B leukemia, associated with a leukocyte count of less than 20,000/mm 3 , and hypercalcemia at the time of diagnosis, as it presented itself in our case ( 6 ). Currently, it is suggested that the presence of hypercalcemia in children with leukemia does not affect their prognosis ( 9 ).…”

“…Hypercalcemia can be present in approximately 0.5%–1.5% of malignancies ( 5 ). In adults, it is mostly described in solid tumors ( 6 ) and in some rare situations associated with acute leukemia or chronic myeloid leukemia, mainly in the accelerated phases of the disease or blast phase ( 6 , 7 ).…”

“…Zoledronic acid in a single dose of 4 mg as an IV infusion over at least 15 min is recommended for the initial treatment of malignant hypercalcemia ( 9 ). However, some case reports have shown effective doses from a single dose of 0.025 mg/kg ( 17 ), 2 mg/kg ( 6 ), or 4 mg in the infusion of 30 min with 100 ml of isotonic saline solution ( 9 ). The adverse effects of zoledronic acid are common in the days after its administration and include acute phase reactions (flu-like symptoms), hypocalcemia, hypophosphatemia, and, less frequently, kidney damage; hence, monitoring and management of these complications must be strict and periodic ( 9 ).…”

Hypercalcemia and Osteolytic Lesions as Presenting Symptoms of Acute Lymphoblastic Leukemia in Children: Case Report and Literature Review

“…The blood calcium decreased to normal range within 48 h with one dose of zoledronic acid (0.05 mg/kg) ( 6 ). Bota et al reported that a 6-year-old child with ALL combined with hypercalcemia developed hypocalcemia 2 days after receiving calcitonin (4 U/kg, q12 h) and zoledronic acid (2 mg) ( 12 ). Therefore, in order to avoid rebound hypocalcemia, it is recommended to initiate zoledronic acid (0.0125–0.05 mg/kg) and pamidronate disodium (0.25–2 mg/kg, maximum 60 mg) at a small dose, and the duration of therapy should be limited to avoid hypocalcemia, hand and foot convulsions, etc.…”

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“…The blood calcium decreased to normal range within 48 h with one dose of zoledronic acid (0.05 mg/kg) (6). Bota et al reported that a 6-year-old child with ALL combined with hypercalcemia developed hypocalcemia 2 days after receiving calcitonin (4 U/kg, q12 h) and zoledronic acid (2 mg) (12). Therefore, in order to avoid rebound hypocalcemia, it is recommended to initiate zoledronic acid (0.0125-0.05 mg/kg) and pamidronate disodium (0.25-2 mg/kg, maximum 60 mg) at a small dose, and the duration of therapy should be limited to avoid hypocalcemia, hand and foot convulsions, etc.…”