Acute myeloid leukemia

Introduction to acute granulocyte leukemia Acute leukemia (AL) is a clonal malignant disease derived from hematopoietic stem cells. Excessive proliferation of any type of abnormal primitive or immature cells in bone marrow and other hematopoietic tissues, and released into the peripheral blood, causing inhibition of other cells in the bone marrow and infiltration of leukemia cells from various organs. Clinical manifestations of anemia, secondary infection, hemorrhage, hepatosplenomegaly and other infiltration. One or more of the original and immature cells in the bone marrow are elevated, with cytoplasmic changes (such as nuclear malformations), elevated white blood cells, red blood cells and thrombocytopenia or reduced whole blood cells, and a large number of immature cells. The disease develops rapidly and the natural course is only a few months. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific population Mode of infection: non-infectious Complications: gastrointestinal bleeding upper respiratory tract infection pneumonia

Cause of acute myeloid leukemia

The etiology of leukemia is complex and has not been fully recognized so far. Many factors are related to the pathogenesis of white blood cells, such as viral infections, radionuclide exposure, chemical factors, drugs and genetic factors. Leukemia children and adults under the age of 35 are the first, the disease develops rapidly, and the course of disease is only a few months. The etiology and pathogenesis of leukemia are complicated, and it is difficult for chemotherapy drugs to completely eliminate leukemia cells in the body, so the prognosis is extremely poor.

The etiology of acute leukemia is related to viral infection, chemical factors, ionizing radiation and other factors:

1. Viral infection: Studies over the past decade have suggested that leukemia is most likely caused by a virus. The virus causes leukemia in poultry, mice, rats, guinea pigs, cats, dogs, cattle, pigs, and monkeys. In addition, C-type RNA tumor viruses are currently thought to be involved in the etiology of human leukemia.

2. Ionizing radiation: The incidence of leukemia after the explosion of the atomic bomb in Hiroshima, Japan has increased significantly. The closer to the center of the explosion, the higher the incidence. In addition, high-dose radiation local treatment of rheumatoid ankylosing spondylitis, the incidence of leukemia in the treatment group was 10 times higher than the control group, and its incidence is closely related to the dose of radiation. Some countries report that radiologists have more leukemia.

3. Chemical factors: Certain chemicals, such as benzene and chloramphenicol, can also induce leukemia by damaging the bone marrow. Acute leukemia may be associated with oral chloramphenicol. Others include aminopyrine, sulfa drugs, phenylbutazone, 223, dimethoate and the like.

4. Genetic factors: The literature reports that leukemia in patients with congenital dementia is 15 to 20 times higher than that in normal children; other congenital diseases with chromosomal abnormalities such as Bloom syndrome, Fanconi syndrome, Klinefelter syndrome, etc. The incidence rate is also high. There are a few familial and congenital leukemias.

Acute myelogenous leukemia prevention

Maintain skin integrity: 1 Avoid possible physical injury, 2 Avoid using steel plates or fine mesh rapiers to trim nails and use electric razors to shave beards; 3 Avoid wearing tight clothing, rough textiles and using tourniquets.

Maintain oral mucosal integrity: 1 Eat soft-toned foods to avoid foods that cause temperature, mechanical and chemical irritations; 2 Use a soft-bristled toothbrush to gently clean the mouth, rinse with a low-alcohol mouthwash, and avoid flossing. Lubricate the lips with Vaseline.

Maintain gastrointestinal mucosal integrity: 1 promote water intake, and increase the amount of activity to avoid constipation; 2 prevent constipation, routinely give soft stool or Chinese medicine decoction conditioning; 3 to avoid rectal invading human treatment measures, such as Use enema, suppository and anus

Acute granulocytic leukemia maintains upper respiratory tract mucosal integrity: 1 keeps the nasal mucosa moist; 2 increases air humidity, maintains home humidity at 40%; 3 immediately sits up when nosebleeds, and exerts pressure on the nostrils under the bridge of the nose.

Maintain genitourinary mucosal integrity: 1 daily water intake 3000ml or more: 2 avoid vaginal lavage and use vaginal suppositories; 3 guide the use of water-soluble lubricants before sexual intercourse; 4 use female hormones under the guidance of a physician if necessary to prevent Menstrual cramps.

Avoid elevated intracranial pressure: When platelets <20x109/L, avoid forced breathing and intense activity.

Acute granulocyte leukemia complications Complications, gastrointestinal bleeding, upper respiratory tract infection, pneumonia

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.

Symptoms of acute myeloid leukemia Common symptoms Persistent fever Chronic anemia Lymph node enlargement Skin mucosal bleeding Skin bleeding Point mouth bleeding

Clinical manifestations: acute leukocyte disease can be divided into acute lymphocytic leukemia (referred to as acute lymphoblast, including type 1, 2, 3) and acute non-lymphocytic leukemia (referred to as acute non-leaching, can be divided into 1~7 type) The clinically common types are acute non-leaching type 1 (granulocyte leukemia), type 5 (monocyte type) and acute drenching type 1~3.

Its performance is as follows:

1 Anemia is closely related to bone marrow manufacturing disorders; granulocytes and promyelocytes in the blood of patients increase, but mature leukocytes decrease, and reticulocytes do not rise compared with iron deficiency anemia.

2 fever, mainly due to infection; abnormal white blood cells in patients with abnormal differentiation are not mature, and do not help the immune system.

3 bleeding to the skin, gums, oral and nasal mucosal bleeding is the most common, heavy throughout the body;

4 leukemia cell infiltration: spleen and hepatomegaly, sternal at the lower end of the pain, sputum pain, eyelid green tumor, lymphadenopathy, central leukemia (headache, vomiting, convulsions, blurred vision, papilledema, coma to death), etc. . The disease mainly depends on blood test and bone marrow diagnosis.

Examination of acute myeloid leukemia

Physical examination: appearance of anemia, skin visible spots, ecchymosis, bleeding of the gums or hyperplasia of the gums, swollen lymph nodes, tenderness of the lower middle sternum, mild hepatosplenomegaly, moderate swelling.

Auxiliary examination: blood picture shows progressive reduction of platelets, white blood cell count can be increased or decreased, and raw or immature cells can be classified.

Bone marrow shows proliferative activity to extreme activity, with bone marrow fibrosis 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 granulocyte leukemia

Diagnostic criteria

1, clinical symptoms: sudden high fever, progressive anemia or significant bleeding, sore body weakness.

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

3. Laboratory:

A, blood: white blood cells are always significantly increased (or reduced), can appear primitive or immature cells.

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%, the proportion of primordial cells in non-erythroid cells 30 % can be diagnosed as acute erythroleukemia.

Differential diagnosis

A, aplastic anemia.

B, myelodysplastic syndrome.

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