Acute leukemia

Introduction to acute leukemia Acute leukemia is a malignant transformation of one or more hematopoietic stem cells and progenitor cells, losing normal proliferation, differentiation and maturation, uncontrolled continuous proliferation, gradually replacing bone marrow and invading the whole body tissues and organs through blood. It is a malignant tumor of hematopoietic tissue, commonly known as blood cancer. It is characterized by the tumorous proliferation of leukemia cells in the bone marrow, invading each organ of the human body, impairing the function of organs, and producing corresponding clinical manifestations. Bone marrow examination is the main basis for the diagnosis of this disease. Acute leukemia is mainly divided into acute lymphoblastic leukemia and acute non-lymphocytic leukemia. Men are slightly more than women. basic knowledge The proportion of illness: 0.006% Susceptible population: males are slightly more than females Mode of infection: non-infectious Complications: sepsis pneumonia upper respiratory tract infection herpes simplex hyperuricemia disseminated intravascular coagulation

Cause of acute leukemia

Virus (10%):

The etiology of human leukemia has been studied for decades. However, only adult T-cell leukemia has been caused by viruses. Other types of leukemia have not been able to confirm their viral factors and are not contagious.

Ionizing radiation and chemicals (15%):

Ionizing radiation has a leukemia-like effect, and its effect is related to the size of the radiation dose and the irradiation site. A large dose or multiple doses of radiation may cause leukemia. The effect of benzene on leukemia is relatively positive. Benzene-induced acute leukemia is caused by acute granules and erythroleukemia.

Genetic factors (15%):

Genetics refers to the characteristics of the progeny obtained by the transmission of genes. Genetics is a discipline that studies this phenomenon. It is currently known that life on Earth is mainly based on DNA as a genetic material. In addition to heredity, the factors that determine biological characteristics are the environment, and the interaction of environment and heredity. The onset of certain leukemias is related to genetic factors.

Acute leukemia is clinically divided into acute myeloblastic leukemia (AML) and acute lymphoblastic leukemia (ALL).

Acute leukemia prevention

prevention

1. Any staff member who is exposed to ionizing radiation and toxic chemical substances such as benzene and its derivatives at work should strengthen protective measures, carefully follow the routine of work, conduct regular physical examinations, and actively treat a large amount of abnormal blood.

2, there are festivals in life, the residence is common, avoiding the cold and heat, work and rest, so that the body is in a good state, the so-called: "righteousness and bones, evil can not do."

3, people should remain optimistic, comfortable, and avoid anger, the so-called: "spiritual self-defense, illness and safety."

Nursing

1. Mental care: Medical staff and their families should make the patient's mood stable, overcome the pessimistic disappointment of the disease, encourage patients to actively fight the disease, and cooperate well with the treatment.

2, pay attention to the patient's rest: especially during the treatment of unstable conditions, reduce or avoid visits, avoid activities in public places.

3, oral and perianal cleansing care: urge patients to use daily light saline, hydrogen peroxide, nitrofurazone containing sputum or scutellaria scutellariae to prevent oral infections; keep the urine and urine smooth, pay attention to cleanliness, prevent skin and mucous membrane infections, You can use the succulent sauce and dandelion to wash the perianal.

4, nutrition catering: to allow patients to eat nutritious, delicious food, vitamins, high protein content of food such as fresh vegetables, fish, eggs, poultry, meat, turtles, etc., eat spicy products, such as onions, peppers Wait.

5, encourage patients to drink more water, eat fresh fruit, avoid alcohol and tobacco.

6, indoors to keep the air fresh, the ground should be clean and disinfection, medical staff should wear a mask.

[prognosis]

1, acute leukemia, frequent onset, if not timely and correct treatment of the disease rapidly deteriorated, especially combined infection, bleeding and more serious, is the main cause of death.

2. In recent years, due to the development of immunology and molecular medicine, the diagnosis of acute leukemia has evolved from cell morphology, histochemistry to cellular immunological markers, genetics, molecular medicine, and new therapeutic anti-leukemia drugs. The emergence and development of cell dynamics and the application of many effective supportive therapies and techniques have significantly improved the efficacy of acute leukemia. For example, in children with acute lymphoblastic leukemia, the complete remission rate is over 95%, and the three-year disease-free survival rate has exceeded 50%, it is currently believed that a considerable number of children have been cured, and the complete remission rate of adult acute lymphoblastic leukemia and acute myeloid leukemia (urgent non-leaching) has reached more than 60%, and the long-term disease-free survival rate is close to 30%.

Acute leukemia complications Complications sepsis pneumonia upper respiratory tract infection herpes simplex uric acid disseminated intravascular coagulation

1, infection: due to leukemia caused by normal leukopenia, especially neutropenia, and chemotherapy and other factors also lead to granulocyte deficiency, making patients prone to serious infection or sepsis, often caused by infection bacteria: Gram-positive Bacteria, such as Staphylococcus aureus, hemolytic streptococcus, coryneform bacteria and other Gram-negative bacilli, such as Pseudomonas aeruginosa, large intestine varicella zoster virus, herpes simplex virus, etc., in addition to Pneumocystis carinii infection, also on Respiratory infections and pneumonia are common types.

2, intestinal failure: due to the treatment of leukemia chemotherapy drugs, radiotherapy means affecting gastrointestinal function, resulting in fear of gastric failure bacteria, Klebsiella, etc., mold infection with Candida albicans, Aspergillus, Mucor mold expansion hair For spores, etc., the above-mentioned fungal infections occur in patients with long-term neutropenia or persistent fever and antibiotics are not sensitive. Some patients receiving corticosteroid treatment are more susceptible to viral infection due to low cellular immune function, such as patient nutrition. Supplementation has become a prominent problem. At present, the use of subclavian vein cannula to the superior vena cava for high-nutrient infusion only solves some problems. Nutritional deficiency can cause complications such as pneumonia and enteritis.

3, high uric acid blood syndrome: normal people due to nucleic acid metabolism decomposition, daily urinary excretion of uric acid 300 ~ 500mg, leukemia patients due to a large number of leukemia cell nucleic acid decomposition can increase uric acid output by dozens of times, when patients receive chemotherapy, radiotherapy and other treatment When there is hyperuricemia, the application of corticosteroids can increase hyperuricemia, high concentrations of uric acid quickly supersaturated and precipitate, causing extensive damage to kidneys and uric acid stones, which can lead to oliguria, no urine, and therefore leukemia Patients must be supplemented with adequate fluids to ensure a certain amount of urine, and take allopurinol. If renal failure occurs, the amount of fluid should be limited and dialysis should be given.

4, hemorrhage: leukemia patients due to leukemia cell malignant hyperplasia, platelet significantly reduced, easy to cause respiratory, digestive tract, urinary bleeding, especially intracranial hemorrhage, so according to the cause of active hemostasis, including infusion of concentrated platelets.

5, lung disease: due to leukemia patients with normal mature neutrophils, immune function is reduced, often leading to lung infection, in addition to leukemia cells, infiltration can block small blood vessels in the lungs, bronchial dyspnea, respiratory distress syndrome, The chest radiograph can be hairy glass or miliary mesh, which can be used for experimental treatment of lung radiation.

6, electrolyte imbalance: white cumulative disease treatment process often due to excessive destruction of leukemia cells or due to chemotherapy drug-induced renal damage and other reasons for excessive potassium, but also due to chemotherapy caused by poor appetite, digestive system dysfunction, the lack of inclusion Hypokalemia, or the release of leukemia cells causes increased phosphorus release, resulting in low calcium, etc. Therefore, attention should be paid to the electrolyte concentrations such as potassium, calcium and sodium during the treatment.

7, disseminated intravascular coagulation (DIC): disseminated blood vessels is a group of severe bleeding syndrome.

Symptoms of acute leukemia Common symptoms Post-sternal burning pain Unexplained Causes Febrile bleeding tends to reduce libido Lymph node enlargement Thoracic tenderness Appetite deficiency Tire diarrhea Intravascular coagulation

1. The onset of leukemia is rapid or slow. Children and adolescents have frequent onset of symptoms. Common first-episode symptoms include: fever, progressive anemia, significant bleeding tendency or bone and joint pain, etc. Young patients are mostly, and their condition is gradually progressing. These patients are often fatigued, weak, pale, tired and short of appetite, lack of appetite, weight loss or fever of unknown origin. In addition, a small number of patients can have convulsions, blindness, and toothache. The gums are swollen, the pericardial effusion, and the lower extremity paraplegia are the first symptoms.

2, fever and infection

A, fever is one of the most common symptoms of leukemia, can occur in different stages of the disease and have different degrees of fever and heat type, the main cause of fever is infection, which is the most common angina, stomatitis, perianal inflammation , pneumonia, tonsillitis, gingivitis, perianal abscess, etc. are also more common, ear inflammation, enteritis, sputum, pyelonephritis, etc. can also be seen, severe infection can also occur sepsis, sepsis and so on.

B. Infected pathogens are more common in bacteria. In the early stage of the disease, Gram-positive cocci are the main cause. Although viral infection is rare, it is often more dangerous. Cytomegalovirus, measles or varicella virus infection is easy to develop pneumonia.

3, hemorrhage is also a common symptom of leukemia, bleeding can be spread throughout the body, skin, gums, nasal bleeding is the most common, but also retina, intra-abdominal bleeding and intracranial, digestive tract, respiratory tract and other visceral bleeding, female menstruation It is also more common and may be the first symptom. The M3 and M5 subtypes of AML are more severely bleeding, especially in patients with M3 who are complicated by diffuse intravascular coagulation (DIC) and intracranial hemorrhage.

4, anemia can occur early, a few cases can appear refractory anemia several months or years before the diagnosis, and later developed into leukemia, patients often accompanied by fatigue, pale, palpitations, shortness of breath, lower extremity edema and other symptoms, Anemia can be seen in all types of leukemia, but more common in elderly AML patients, many patients often with anemia as the first symptom.

Acute leukemia examination

Physical examination found

Anemia appearance, skin visible sputum, ecchymosis, gingival bleeding or gingival hyperplasia, lymphadenopathy, tenderness in the middle and lower sternum, mild liver and spleen, moderate swelling.

Auxiliary inspection

Blood: Hemoglobin, platelets progressively reduce, white blood cell count can be increased or decreased, and the original or immature cells can be classified.

Bone marrow: hyperplasia is extremely active, may be associated with myelofibrosis or bone marrow necrosis. According to the series of proliferating cells, it is divided into acute non-lymphocytic leukemia (ANLL) and acute lymphoblastic leukemia (ALL). Its bone marrow characteristics are as follows:

(1) ANLL: 1 M1 type (undifferentiated type of acute myeloid leukemia): granulocytes 90% (non-erythroid cells), promyelocytic cells are rare, and the mesenchymal cells are absent or rare in the following stages; Auer bodies are visible. The erythroid and megakaryocyte cell lines are inhibited.

2 M2 type (acute differentiation of acute myeloid leukemia): the granulocyte is obviously proliferated, and the Auer body is visible; the erythroid and megakaryocyte cell lines are inhibited. According to the degree of granulocyte differentiation, it is further divided into: M2a type: 30% to 90% of protoplasts (non-erythroid cells), <20% of monocytes, and >10% of promyelocytic cells. M2b type: The original and promyelocytic cells increased significantly, but the abnormal neutral neutrophil proliferation was dominant. The nucleus often had nucleoli and the nucleoplasm development was obviously unbalanced. Such cells were >30%.

3 M3 type (acute myelocytic leukemia with acute granules): mainly proliferative promyelocytic hyperplasia with increased particles, such cells >30% (non-erythroid cells); easy to see Auer bodies; erythroid, The proliferation of megakaryocyte cell lines is suppressed. According to the degree of granulocyte differentiation, it is further divided into: M3a type (coarse type): the azurophilic blue particles are coarse, dense or fused. M3b type (fine particle type): The aniline blue particles are dense and small.

4 M4 type (acute granulocyte-monocytic leukemia): granulocyte, monocytic cell proliferation, erythroid, megakaryocyte cell proliferation is inhibited. According to the morphology of granulocyte and monocyte lines, there are four types: M4a: primary and promyelocytic hyperplasia, mononuclear cell line 20% (non-erythroid cells). M4b: primary and young mononuclear cells are predominantly proliferating, and primary and promyelocytes are >20% (non-erythroid cells). M4c: The original cells are granulocyte-series and have a mononuclear cell line morphology >30% (non-erythroid cells). M4Eo: In addition to the above characteristics, there are coarse and round eosinophilic particles and darker basophilic particles, accounting for 5% to 30% (non-erythroid cells).

5M5 type (acute monocytic leukemia): mononuclear cell line hyperplasia, small Auer bodies can be seen; erythroid, granulocyte and megakaryocyte cell lines are inhibited. According to the degree of differentiation of monocytes, it is further divided into: M5a type (undifferentiated type): primordial mononuclear cells 80% (non-erythroid cells). M5b type (partially differentiated type): original, naive >30%, original mononuclear cells <80% (non-erythroid cells).

Type 6M6 (erythroblast): erythrocyte lineage >50%, and morphological abnormalities, non-erythroid cell myeloblasts (or original + naive monocytes >30% (non-erythroid cells); if blood cells are in myeloblasts or Proto-mononuclear cells >5%, myelocytes or primitive + naive monocytes in bone marrow non-erythroid cells >20%. Megakaryocytes are reduced.

Type 7M7 (acute megakaryoblastic leukemia): Proto-megakaryocytes >30%. Red lineage and granulocyte proliferation are relatively inhibited.

(2) ALL : 1 L1 type: the original and naive lymphocytes are obviously proliferating, the proportion is increased, mainly small lymphocytes; the nucleus is round, occasionally concave and folded, the chromatin is coarse, the structure is more consistent, the nucleolus is less, unclear; Less pulp, light or moderate alkalophilic.

2L2 type: the original and naive lymphocytes are obviously proliferated, the proportion is increased, the lymphocytes are different in size, and the large cells are dominant; the nucleus is irregular, the depression and folding are easy to see, the chromatin is loose, the structure is inconsistent, and the nucleolus is clear. One or more; more cytoplasm, mild or moderate alkalophilic.

3L3 type: the original and naive lymphocytes obviously proliferated, the proportion increased, but the cell size was more consistent, mainly large cells; the karyotype was regular, the chromatin was uniform and fine, and the nucleolus was one or more, more obvious, small Bubble shape; the amount of cytoplasm is large, dark blue, vacuoles are often obvious, and are honeycomb-like.

Cytochemical staining:

(1) Peroxidase and Sudan black staining: acute lymphocytes were negative (positive <3%); acute granulocytes were strongly positive; singular cells were positive or weakly positive.

(2) Glycogen staining: acute lymphocytes are positive (coarse or coarse, often on the cytoplasm side); acute granules, acute single cells are weakly positive (diffuse fine granules); erythroleukemia: young red blood cells are Strong positive.

(3) Non-specific esterase staining: acute single cells are strongly positive and can be significantly inhibited by sodium fluoride (>50%); acute or granulocyte is positive or weakly positive, sodium fluoride is mildly inhibited (<50%); Cells are generally negative.

(4) Neutrophil alkaline phosphatase staining: acute leukemia leukemia score increased or normal; acute leukemia was significantly reduced; acute leukemia can be increased or decreased.

Conditions should be done immunology, cytogenetics and genotyping.

Diagnosis and diagnosis of acute leukemia

Diagnostic criteria

1, clinical symptoms, sudden high fever, progressive anemia or significant bleeding, soreness and weakness.

2, signs of skin bleeding spots, sternal tenderness, lymph nodes, hepatosplenomegaly.

3. Laboratory:

A, blood leukocytes always increase (or decrease), and primitive or immature cells can appear.

B, bone marrow, bone marrow nucleated red blood cells account for less than 50% of all nucleated cells, primordial cells 30%, can be diagnosed as acute leukemia; such as bone marrow nucleated red blood cells 50%, primordial cells account for 30% of non-erythroid cells Can be diagnosed as acute erythroleukemia.

Differential diagnosis

A, aplastic anemia.

B, myelodysplastic syndrome.

C, malignant histiocytosis.

D, idiopathic thrombocytopenic purpura.

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