Case description
Patient K. 1996, male, height 174 cm, weight 62 kg, was in inpatient
treatment in the oncohematological department. The disease debuted in
October 2016, with weakness, dizziness, the febrile temperature in the
evenings, shortness of breath, and swollen cervical lymph nodes. Under
the conditions of the NROC, in the department of hematology, the patient
was diagnosed with acute lymphoblastic leukemia (option B III) based on:
- The result of a complete blood count (CBC): leukocytes – 2.4
thousand/μl, thrombocytopenia – 30 thousand/μl, hemoglobin – 65 g/l,
lymphocytes – 50%, monocytes – 1%, neutrophils – 2.9%, blasts –
42%.
- Myelogram: blasts – 80.4%, myelocytes – 0.4%, segmented – 1.6%.
All neutrophils – 2%, monocytes – 0.2%, lymphocytes – 14.8%.
Plasma cells – 0.2%. The puncture of the bone marrow is moderately
cellular. Blast cells of medium to large size with rounded and oval
nuclei, with a delicate chromatin structure with 1-2-3 nucleoli.
Granulocyte and erythroid sprouts are reduced. No megakaryocytes were
found in the preparations.
- Immunophenotyping of bone marrow. In the examined bone marrow sample,
a population of cells CD19 + / CD10 + / CD34- / HLADR- / cytCD22 + /
TDTcyt + / cytlgM + Scd22dim + / CD20dim + / CD13- / CD117- / CD33- /
sIgM- / CD7- / MPO- / CD3-cyt- , which is typical for acute
lymphoblastic leukemia, variant B III is most likely.
- Molecular-cytogenetic examination (FISH-diagnostics). Bone marrow
puncture is a low cell. 150 interphase nuclei with each DNA probe were
analyzed. The t (9:22) (q34: q11) MLL / 11q23 translocation was not
detected in the analyzed interphase nuclei. He received
polychemotherapy (PCT) according to the ALL-2013 KZ protocol.
According to the protocol, the examination of the heart was compulsorily
taken on a standard ECG, which revealed frequent ventricular
extrasystole, an episode of sustained ventricular tachycardia with a
ventricular rate of 166 beats per minute. The patient was consulted by a
cardiologist, after which Holter ECG monitoring was prescribed. During
the study, in the evening, in the department, the patient lost
consciousness and was transferred to oncological intensive care. The
patient’s condition worsened, clinical death occurred due to cardiac
arrhythmias, namely, ventricular pirouette-type tachycardia (Torsade de
Pointes), which turned into ventricular fibrillation (Figure 1). Cardiac
resuscitation was performed immediately, and the rhythm was restored by
Pulsed Electromagnetic Field therapy.
ECG monitoring was carried out in stationary conditions with a duration
of 22:23h. Sinus rhythm, sinus arrhythmia, average heart rate – 77
beats per minute, minimum heart rate – 56 beats per minute (22:58),
maximum heart rate in sinus rhythm – 144 beats per minute (20:19). 3872
ventricular extrasystoles were registered, of which: 2242 single,
bi-tri-quadrigeminal cycles, which in percentage was 2% ventricular
contractions. Life-threatening heart rhythm disturbance was recorded by
1630 episodes of persistent ventricular tachycardia ”Torsade de Pointes”
(TdP), 1 episode of ventricular fibrillation with a rate of 348 beats
per minute lasting 9 minutes, from 20:09 to 20:18 (clinical death)
(Figures 1 and 2). The rhythm was restored by the defibrillator. Also
found in the amount of 360 single supraventricular extrasystoles. At an
average heart rate, the QT interval was 500 msec and the corrected QTc
was 560 msec. It is known that a prolongation of the corrected QTc
interval is a predictor of sudden cardiac death. The maximum R-R –
1.352 sec (22:58), ischemic changes in the ST segment, and the T-wave
was not found.
During polychemotherapy, the patient had multiple infectious
complications against the background of myelotoxic agranulocytosis: on
the 8th day of hospitalization – febrile neutropenia, gram-positive
sepsis (Staphylococcus aureus), and on the 10th day, probable invasive
pulmonary aspergillosis. Given the complications, groups of drugs were
prescribed for treatment: broad-spectrum antibiotics, antimycotic,
hormonal drugs, cytostatics, diuretics, antihistamines, and
anticoagulants. All of these drugs have side effects that could lead to
a prolongation of the QT interval. Prolongation of the QTc interval
during pharmacotherapy in the patient manifested itself as acute
cardiotoxicity: at an average heart rate, QTc was 500 msec and a
corrected QTc of 560 msec (Figure 3). The patient received
antiarrhythmic therapy according to the Cordarone 600mg/s scheme for 2
weeks, then 400 mg/s for 2 weeks, then 200 mg/s for 3 months.
In dynamics, a control Holter ECG monitoring was prescribed a month
later. The study was conducted against the background of antiarrhythmic
therapy. Daily ECG monitoring was carried out in stationary conditions
with a duration of 23:20h. The main rhythm is sinus, sinus arrhythmia,
with an average heart rate of 85 beats per minute, a minimum heart rate
of 56 beats per minute (03:31), a maximum heart rate of 131 beats per
minute (19:40). The ventricular and supraventricular activity was not
registered. Tachycardia – 16%, maximum RR interval – 1.26 seconds
(04:01). QT with the average heart rate is 400 msec and QTc 480 msec.
According to the results of Holter ECG monitoring against the background
of antiarrhythmic therapy, episodes of rhythm disturbances were not
observed.