Hiperkalsemi nedeni ile başvuran bir çocukta nadir bir neden: akut lenfoblastik lösemi

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Introduction
Acute lymphoblastic leukemia (ALL) is the most
common form of acute leukemia in children. ALL
commonly presents with nonspecific features such as
fever, bleeding, musculoskeletal pain or lymphadenopathy (1). ALL in childhood is rarely associated with
hypercalcemia (2).
Hyperparathyroidism, hypervitaminosis A and D,
hyperthyroidism, immobilization and malignancies are the major causes of hypercalcemia. This
case report demonstrates that ALL may present in
an atypical form with nonspecific symptoms such
as hypercalcemia. Repeat laboratory and peripheral
blood smear examinations are important in cases of
hypercalcemia.
Case Report
A 4-year-old boy was admitted to our hospital because of nausea, vomiting, fever, fatigue, weight loss
and an increased intake of water lasting for the last 10
days. His complaints increased significantly on the last
2 days. His vomiting was non-bloody and commonly
occurred after eating. He had no prenatal follow up
and was born in a hospital. His immunizations were
up-to date. The family history was unremarkable.
Physical examination on admission showed lethargy and apathy. His pulse rate was 126/min, axillary
temperature 37.2 ºC, blood pressure 82/58 mmHg,
respiratory rate 26/min, weight 15 kg (25th percentile) and height 99 cm (10-25th percentile). His scleras and oropharanyx were hyperemic, and the oral
mucosa was dry. No hepatomegaly, splenomegaly
or lymphadenopathy were detected. The rest of his
physical examination findings was unremarkable.
The laboratory investigations on admission revealed hemoglobin (Hb) 11.4 gr/dl, white blood cell
(WBC) count 23.400/μl, with neutrophils 40%, lymphocytes 58%, monocytes 2%, platelets 302.000/μl.
Urea level was 76 mg/dl, creatinine 1.1 mg/dl, so-
*Department of Pediatrics, Dicle University Faculty of Medicine
Reprint request: Dr. Mustafa Taşkesen, Department of Pediatrics, Dicle
University Faculty of Medicine, Diyarbakır, Turkey
E-mail: drmtaskesen@hotmail.com
Date submitted: December 24, 2008 • Date accepted: April 06, 200948 • March 2010 • Gulhane Med J Taşkesen et al.
dium 136 mmol/L, potassium 2.8 mmol/L, lactate
dehydrogenase (LDH) 320 U/L, alkaline phosphatase
236 U/L, clor 98 mmol/L, parathyroid hormone 12.8
pg/ml (15-65), urine calcium/creatinine ratio 0.4
mg/mg and serum calcium (Ca) 20.2 mg/dl. Alanine
aminotransferase, aspartate aminotransferase, 25-
OH-VitD3, albumin, magnesium, electrocardiogram,
renal ultrasonography, bone radiographs and thyroid
function tests were normal. The peripheral blood
smear examination was normal.
Hypercalcemia was treated with intravenous isotonic sodium chloride solution, furosemide and
corticosteroid. On day 4 of admission, WBC count
of 8400/μl, Hb level of 12 gr/dl, platelet count of
269.000/μl, Ca 13.5 mg/dl, urea 35 mg/dl, creatinine
0.8 mg/dl, LDH 840 U/L were detected, and peripheral blood smear examination at this time revealed
atypical lymphocytes. A bone marrow aspiration
was performed, which showed the presence of 80%
lymphoblasts. After cytogenetic and flow cytometric
analysis, the patient was diagnosed with ALL of the
B-cell type.
Discussion
ALL in childhood is rarely associated with hypercalcemia (3). Hypercalcemia has been described in
children with hematologic malignancies and solid
tumors (1). Case reports of hypercalcemia with one of
the presenting clinical findings in patients with acute
leukemia have been reported previously (4-6).
Gastrointestinal (nausea, vomiting, anorexia, constipation), neuromuscular (lethargy, fatigue, hypotonia, stupor, coma) and cardiovascular (bradycardia,
arrhythmia) symptoms characterize the clinical spectrum of malignant hypercalcemia (7). Buonuomo
et al. reported a 9-year-old girl who was referred for
abdominal pain, nausea, vomiting, loss of weight
and muscle aches, without polydipsia, polyuria or
constipation. They found hepatomegaly on physical
examination (8). Our patient presented with nausea,
vomiting, fever, fatigue, weight loss, increased intake
of water, and no cardiovascular symptoms, polyuria,
constipation or organomegaly were detected.
Laboratory and radiological findings may be a clue
to the presence of a malignancy as the underlying
diagnosis of hypercalcemia. In the initial laboratory results, radiologic findings and peripheral blood
smear examination of our patient, malignancy was
not detected. On day 4 of admission, a WBC count
of 8400 u/l, Hb level of 12 gr/dl, platelet count of
269000/μl, LDH 840 U/L were noted, and peripheral
blood smear examination at this time revealed atypical lymphocytes.
The initial treatment for hypercalcemia is intensive
hydration and diuretics. If this treatment fails, corticosteroids may be useful (8). Loop diuretics (e.g., furosemide) may be used after correction of dehydration,
with strict fluid and electrolyte monitoring to further
augment urinary calcium excretion (9). An alternative therapy is the administration of biphosphonates,
which are very powerful inhibitors of bone resorption
(1,10). In our case, hypercalcemia was treated with
intensive hydration, furosemide and corticosteroids.
Biphosphonates were not used.
In conclusion, hypercalcemia may be a presenting
laboratory finding of ALL in childhood. The physical
examination and laboratory results (history, physical
examination, laboratory, radiology) may be atypical
for ALL at presentation and a normal complete blood
cell count may be found. Physicians should be aware
of this rare presentation of ALL. Repeat laboratory
and peripheral blood smear examinations are important for differential diagnosis of hypercalcemia.