Intracranial Hemorrhage and a White Blood Cell Count of Almost 1 Million Cells/muL

摘要

A 2-year-old boy with respiratory difficulty and altered mental status was intubated and transferred to our hospital. Examination revealed fever (39.5degC), hypertension (110/76 mmHg), and sinus tachycardia (140 beats/ minute). He appeared pale with abundant petechiae and purpurae; was unresponsive to verbal, tactile, or painful stimuli; and exhibited decerebrate posturing and a "blown" left pupil. Laboratory studies detected profound leukocytosis (white blood cell [WBC] count 966 200 cells/muL) with 93% blasts, anemia (hemoglobin 7.4 g/dL), thrombocytopenia (platelets 42 000/dL), and a prothrombin time of 25.7 seconds (Figure 1, A and B). Head computed tomography scan and magnetic resonance imaging revealed multiple hemorrhages within the supratentorial and infratentorial brain and brainstem (Figure 1, C-F). Cytoreductive leukopheresis followed by continuous veno-venous hemofiltration dialysis was implemented (Figure 2; available at www.jpeds.com). High-dose steroids were administered, hyperventilation was applied, and mannitol was given to reduce cerebral edema. Analysis of bone marrow aspirate confirmed the diagnosis of T lymphoblastic leukemia, and chemotherapy was started. A leukemic remission was achieved by day 8 of induction, and the child was extubated on day 9. One month later, he was in full remission, but his neurologic status remained profoundly altered. He was supported by enteral feeds as his antileukemic therapy continued.