Results
Ninety-three patients met inclusion criteria out of 144 records reviewed
during the study period. Patients were 43% female, of varied races,
21.5% had a medical history (e.g. asthma), none with a personal history
of bleeding and one patient had a family member with documented bleeding
history (menorrhagia) – Table 1. A third of patients had bleeding
symptoms upon presentation, which were most commonly bruising (80.6%)
and petechiae (64.5%).
Patients were diagnosed (via peripheral blood flow and/or bone marrow
studies) predominantly with ALL (82.7%). Of these, 82.9% had pre-B
cell ALL and 17.1% had T-cell ALL. The remainder of diagnoses were AML
(12.9%), APML (3.2%), biphenotypic leukemia (2.2%), and mature B cell
leukemia (2.2%). All patients underwent a lumbar puncture (LP), bone
marrow aspirate (and bone marrow biopsy for some patients) along with
CVL placement for chemotherapy. One patient was diagnosed via fluid from
a pleural effusion.
Two patients had minor bleeding (both WHO grade 2) noted at a procedure
site. One patient had a bleed at the LP site (day 2 post-procedure),
with normal PT/aPTT at presentation; bleeding was attributed to
thrombocytopenia which resolved with a pressure bandage. The second
patient had bleeding at the CVL site (day 1 post-procedure) and had
presented with a PT of 13.9. This was not corrected initially, but
patient was initiated on a course of vitamin K for the CVL site bleed.
Laboratory data are also presented in Table 1. The median age at
diagnosis was 8 years (interquartile range [IQR] 3-12) with
hematologic lab values as follows: white blood cell count (WBC) with
leukocytosis (median 15.7; IQR 5.3-57.2), anemia with hemoglobin 8.1
(5.7-10.4), thrombocytopenia with platelets 64 (24-119), mildly
prolonged prothrombin time (PT) at 13.2 (12.4-15.4), and normal partial
thromboplastin time at 31 (27.4-33.6). Fibrinogen (343; 227-465) and
D-dimer (834; 341-2869) were obtained in 37.6% and 22.5% of patients
respectively, which were both elevated. Chemistries were obtained, most
notably with an elevated LDH (637; 368-1218).
Prolonged PT was found in over half of patients (N=51, 54.8%) and only
5 had prolonged aPTT (5.4%). Of interest, 84.6% (11 of 13) patients
with T cell leukemia had prolonged PT, along with 58.3% of patients
with AML, and all 3 patients with APML. In our cohort, less than 27% of
patients with prolonged PT/aPTT had factor levels obtained; of those,
factor VII had the lowest activity with a median of 33.1% (19.4-50.5).
Varying blood products were administered for prophylaxis per institution
guidelines prior to procedures (for hemoglobin <8 g/dL,
platelets <10 K/uL, PT >15 s). Red blood cells
(RBCs) were administered in 41.2% of patients, platelets in 52.9%, FFP
in 7.8% and vitamin K in 21.6%.
Anemia and thrombocytopenia did not appear to correlate with prolonged
PT (p=0.73 and p=0.18 respectively), nor with prolonged aPTT (p=0.52 and
0.42 respectively). Leukocytosis, however, showed significant
correlation with elevated PT (p<0.001), but not aPTT (p=0.3)
– Figure 1. This was also seen with elevated absolute neutrophil count
with elevated PT (p<0.01), but not aPTT (p=0.5). Bleeding
symptoms did not correlate with prolonged PT (p=0.83), prolonged aPTT
(p=1) or anemia (p=0.06), but had significant correlation with
thrombocytopenia (p=<0.0001) and elevated AST (p=0.05).