Antineoplastics
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Reactions 1193 - 15 Mar 2008 S Antineoplastics Fatal adenovirus hepatitis in a child: case report A 3.5-year-old boy developed fatal adenovirus hepatitis during maintenance chemotherapy for childhood acute lymphoblastic leukaemia. The boy started receiving chemotherapy according to the POG 9201 protocol [specific drug(s), dosage(s) and duration of treatment(s) not stated] and achieved complete remission. During week 121 of maintenance therapy, he presented with dry cough, rhinitis and febrile neutropenia. At this time, he was receiving oral mercaptopurine 75 mg/m 2 /day and oral methotrexate 20 mg/m 2 /week. One week before admission, he received one vincristine 1.5 mg/m 2 dose, oral dexamethasone 6 mg/m 2 /day for 7 days, and intrathecal methotrexate as per the protocol [dosage not stated]. Antineoplastics were discontinued on the day of admission, due to low WBC and lymphocyte counts (0.6 × 10 9 /L and 0.13 × 10 9 /L, respectively). The boy received IV amikacin and ceftriaxone. He had elevated liver transaminase levels (ALT 22 times the upper limit of normal (ULN); AST 8 times the ULN), which were initially thought to be due to chemotherapy. The next day, direct immunofluorescence of nasopharyngeal aspirate detected adenovirus. Over the following days, his transaminase levels steadily increased. His cholestatic parameters and amylase levels also increased and coagulation tests became abnormal. He received IV vitamin K and immune globulin. He had persistent severe neutropenia and fever, and antibacterials were changed to vancomycin and meropenem; he also received voriconazole. On day 6, diagnostic tests for disseminated adenovirus infection were conducted. He received cidofovir, intensified IV hydration and probenecid. Liver biopsy findings, qualitative PCR analysis and viral culture tests were consistent with adenovirus hepatitis. Quantitative real-time PCR detected > 10 9 adenoviral DNA copies/mL of blood. Adenovirus was identified as serotype 2. Seven days after admission, he developed coagulopathy with severe bleeding from the nasopharynx and gastrointestinal tract. He also had pulmonary and intraperitoneal haemorrhage, despite administration of eptacog [recombinant factor VIIa], tranexamic acid, protamine sulfate and fresh frozen plasma. He was intubated, but sufficient oxygenation became impossible. He developed multiorgan failure and generalised seizures, suggestive of intracranial haemorrhage and/or severe cerebral hypoxaemia. Intensive life support was discontinued and he died 10 days after admission. Steiner I, et al. Fatal adenovirus hepatitis during maintenance therapy for childhood acute lymphoblastic leukemia. Pediatric Blood and Cancer 50: 647-649, No. 3, Mar 2008 - Switzerland 801103198 1 Reactions 15 Mar 2008 No. 1193 0114-9954/10/1193-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Transcript of Antineoplastics
Reactions 1193 - 15 Mar 2008
SAntineoplastics
Fatal adenovirus hepatitis in a child: case reportA 3.5-year-old boy developed fatal adenovirus hepatitis
during maintenance chemotherapy for childhood acutelymphoblastic leukaemia.
The boy started receiving chemotherapy according to thePOG 9201 protocol [specific drug(s), dosage(s) and duration oftreatment(s) not stated] and achieved complete remission.During week 121 of maintenance therapy, he presented withdry cough, rhinitis and febrile neutropenia. At this time, he wasreceiving oral mercaptopurine 75 mg/m2/day and oralmethotrexate 20 mg/m2/week. One week before admission, hereceived one vincristine 1.5 mg/m2 dose, oral dexamethasone6 mg/m2/day for 7 days, and intrathecal methotrexate as perthe protocol [dosage not stated].
Antineoplastics were discontinued on the day of admission,due to low WBC and lymphocyte counts (0.6 × 109/L and0.13 × 109/L, respectively). The boy received IV amikacin andceftriaxone. He had elevated liver transaminase levels (ALT22 times the upper limit of normal (ULN); AST 8 times theULN), which were initially thought to be due to chemotherapy.The next day, direct immunofluorescence of nasopharyngealaspirate detected adenovirus. Over the following days, histransaminase levels steadily increased. His cholestaticparameters and amylase levels also increased and coagulationtests became abnormal. He received IV vitamin K and immuneglobulin. He had persistent severe neutropenia and fever, andantibacterials were changed to vancomycin and meropenem;he also received voriconazole. On day 6, diagnostic tests fordisseminated adenovirus infection were conducted. Hereceived cidofovir, intensified IV hydration and probenecid.Liver biopsy findings, qualitative PCR analysis and viral culturetests were consistent with adenovirus hepatitis. Quantitativereal-time PCR detected > 109 adenoviral DNA copies/mL ofblood. Adenovirus was identified as serotype 2. Seven daysafter admission, he developed coagulopathy with severebleeding from the nasopharynx and gastrointestinal tract. Healso had pulmonary and intraperitoneal haemorrhage, despiteadministration of eptacog [recombinant factor VIIa],tranexamic acid, protamine sulfate and fresh frozen plasma.He was intubated, but sufficient oxygenation becameimpossible. He developed multiorgan failure and generalisedseizures, suggestive of intracranial haemorrhage and/or severecerebral hypoxaemia. Intensive life support was discontinuedand he died 10 days after admission.Steiner I, et al. Fatal adenovirus hepatitis during maintenance therapy forchildhood acute lymphoblastic leukemia. Pediatric Blood and Cancer 50: 647-649,No. 3, Mar 2008 - Switzerland 801103198
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Reactions 15 Mar 2008 No. 11930114-9954/10/1193-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
