Hematopoietic stem cell transplant versus chemotherapy plus tyrosine kinase inhibitor in the treatment of pediatric Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL)

Background: Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) remained until recently the molecular genetic abnormality associated with the worst outcome. Hematopoietic stem cell transplant (HSCT) was considered the treatment of choice, however, recent data have indicated that chemotherapy plus tyrosine kinase inhibitor (TKI) maybe an alternative effective therapy. Methods: We conducted a retrospective analysis of children (<18 years) with Ph+ ALL who were treated at King Hussein Cancer Center (KHCC) from January 2003 till December 2011. Results: Over a 9 year period, 411 children were diagnosed and treated for ALL at KHCC. Twenty three (6.6%) had Ph+ ALL; 16 males and 7 females. Median age at diagnosis was 9.5 years (range 1.67–17). The median white blood cell count was 58.6 × 103/μL (range 1.6–459). Twelve patients underwent HSCT from a full matched related donor; and 10 were treated with intensive chemotherapy plus TKI (imatinib). Those who underwent HSCT were significantly older (P = 0.004) and had a higher leukocyte count at diagnosis (P = 0.53). After a median follow up of 42.2 months (range 12.7–107), the estimated 5 year event free survival (EFS) and overall survival (OS) were 75% and 91.6%, respectively, for those who underwent HSCT as primary therapy and 49.3% and 83.3%, respectively, for those treated with chemotherapy plus imatinib. There was no significant difference in EFS (P = 0.98) or OS (P = 1) between the two treatment modalities. Conclusions: Our results indicate that chemotherapy plus TKI may be a reasonable treatment option for some children with Ph+ ALL

Empirical treatment with parenteral acyclovir in a child with herpes simplex virus hepatitis and acute lymphoblastic leukemia

Introduction: Hepatitis secondary to Herpes Simplex Virus (HSV) infection is a complication that often leads to fatal hepatic failure. Early treatment with the anti-viral drug, acyclovir, is life-saving. In view of the non-specific nature of the signs and symptoms associated with HSV hepatitis, diagnosis is often made late during the course of the disease; a factor that largely contributes to the high mortality rate of this treatable disease complication. There is thus a growing consensus in the field to initiate empirical treatment with acyclovir once suspicion of HSV hepatitis is raised even before reaching a conclusive diagnosis. Presentation of case: We present clinical evidence on the benefit of starting empirical acyclovir treatment on the outcome of patients suffering from HSV hepatitis. We report two cases of HSV hepatitis in children with cancer. One case presented with fulminant hepatitis which was fatal and the diagnosis was only reached post mortem. In the second case, there was enough suspicion of HSV hepatitis to start early empirical acyclovir therapy. The diagnosis was confirmed 48 hours following the initiation of treatment and the early intervention with anti-virals proved to be life-saving. Discussion: In both cases above, the following symptoms were shared; fever, elevated transaminase levels and mucositis without clear cutaneous lesions. HSV hepatitis should thus be considered in the differential diagnosis of immuonocomprimised patients exhibiting the above symptoms. Conclusion: Due to the frequent delay in HSV diagnosis and the safety of acyclovir, we recommend empirically administering acyclovir in patients suspected of HSV hepatitis. Keywords: Herpes simplex virus, Hepatitis, Acyclovir, Empirical treatment, Acute lymphoblastic leukemi