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Intussusception as a cause of death in acute leukemia
Volume 63
Number 3
Brie[ clinical and laboratory observations
4 6 3
aerator p u m p +~ m o u n t e d in a plywood a n d h a r d w a r e - c l o t h box to keep fingers out of the machinery. These p u m p s are assembled to deliver positive pressure. T h e i r valves are easily reversed to convert t h e m to suction.
OPERATION W h e n connections are complete, the p u m p is started a n d operates continually. This results in constant suction and airflow t h r o u g h the system. W h e n the baby voids, urine is rapidly sucked from the cup a n d t r a p p e d in the bottle. Occasionally urines are needed from uncooperative or unconscious older children. F o r them, the b o t t o m is cut from a s t a n d a r d plastic urine collector a n d this is a t t a c h e d to the cup with adhesive. T h e soft plastic collector is then fixed to the perineum as usual. T h e device facilitates nursing care of the infant. H e can be h a n d l e d rather freely for feeding, bathing, and dressing. U n d o u b t e d l y , the use of a m e c h a n i c a l device adds enough "busyness" to the p r o c e d u r e to remind tile attendants that something i m p o r t a n t is going on.
Fig. 1. plastic tube connects the cup to a length of glass tubing in a two-hole stopper fitted to tile collection bottle. This inlet should extend into the bottle an inch or so beyond the orifice of the suction tube.
THE P U M P A similar suction tube, connected to the outlet of the collecting jar, is taken to the p u m p (B). T h i s is an inexpensive a q u a r i u m
--,ntmsusceptwas n a cause ro] death in acute leukemia
Report of a
case
Bernard H. Feldman, Lieutenant (MC) USN, and F r e d e r i c A. Schulaner, L i e u t e n a n t ( M C ) U S N
CASE R E P O R T
H • ~a o R R H A G E ~ a universal occurrence in leukemia, is often responsible for the patient's death. W e present an instance where h e m o r r h a g e p l a y e d an unusual role in the patient's clinical course.
A 5-year-old Caucasian female was admitted initially to the United States Naval Hospital, Bethesda, Md., in June, I961, with a mass in the scalp. The diagnosis of lymphosarcoma was
From the United States Naval Hospital, Bethesda 14, Md. The opinions expressed herein are those o/the authors and do not reflect necessarily the views o[ the Navy Departraent.
~Glo-Lite "Jet-88" Aerator, Model 1010, Glo-Lite Manufacturing Company, 117 East 129th Street, New York 35, N. Y. has worked well.
4 64
Brief clinical and laboratory observations
September 1963
A-C Fig. 1. A, Gross specimen of intussuscepted bowel with proximal end to the right. B, Crosssection of (A) showing intramural hematoma at apex of intussusceptum. C, Photomicrograph of intussuscepted bowel. made by excisional biopsy and postoperative irradiation was administered. She did well until November, 1961, at which time she developed acute lymphoblastic leukemia. During the following 4 months, she was treated with 6-mercaptopurine and, when relapse occurred, received a folic acid antagonist~; steroids were used intermittently when bleeding was severe. Her final admission in August, t962, occurred because of the progressive development over a 3 day period of abdominal pain, abdominal distention, constipation, and somnolence. The patient was febrile, lethargic, and cried out occasionally as if in pain. The abdomen was tense, tympanitic, free of masses other than an enlarged liver and spleen, and there was a paucity of bowel sounds. Petechiae were minimal in number. The white blood count was 4,490 per cubic millimeter with a shift to the left in the white blood count; the lymphoblasts numbered 1 per cent. The hemoglobin level was 11.2 Gm. per 100 ml.; the platelet count was 11,000 cubic millimeter. The bone marrow was hypercellular and showed marked lymphoblastic proliferation. Spinal fluid examination was unremarkable. Coliform bacilli were found by blood culture. An upright roentgenogram of the abdomen demonstrated fluid levels. Gastric suction, antibiotic therapy, and supportive measures were used but the patient lived less than 48 hours, during which time neither decompression of the bowel nor return of bowel sounds occurred. No blood was passed per rectum. At autopsy, multiple ecchymoses of the small bowel were present as well as four areas of intussuscepted ileum. From their appearance, it was evident that the intussusceptions occurred ante-mortem. Most of the intussuscepted bowel was gangrenous. On cut section, it was noted that ~Methotrexate, manufactured by Lederle Pearl River, N. Y.
Laboratories,
an intramural hematoma was the leading point of each intussusceptum (Fig. 1). DISCUSSION Intussusception in association with leukemia has been reported only rarely?' ~ I n what appears to be the first documented case, 1 a polypoid mass i n the upper ileum was found at the apex of an intussusception. Microscopic e x a m i n a t i o n revealed hyperplasia of lymphoid tissue. I n the case recorded by T h o m p s o n a n d Posel, 2 and in our own, an i n t r a m u r a l h e m a t o m a of the small bowel provided a leading point for peristaltic invagination. Except in infancy, an exciting factor is usually found as a cause of the intussusception. O f t e n this exciting factor m a y be a tumor. L e u k e m i a can produce such a tumor' either by lymphocytic infiltration a n d hyperplasia of a polypoid n a t u r e or by intram u r a l extravasation of blood with the formation of hematomas. A b d o m i n a l p a i n is a rather c o m m o n occurrence in leukemia and has been explained by extensive e n l a r g e m e n t of the abdominal l y m p h nodes? These cases would suggest that intussusception should be classified as a rarer cause of a b d o m i n a l pain in acute leukemia as well as one of the m a n y ways in which h e m o r r h a g e m a y present. SUMMARY
A 5-year-old, leukemic child with intussusception as the immediate cause of death is described. T h e association of these two conditions is extremely rare, b u t it
Volume 63 Number 3
would a p p e a r that intussusception m a y be the result of i n t r a m u r a l intestinal hemorrhage resulting from acute leukemia. REFERENCES
1. Sinclair; N.: Intussusception complicating lymphatic leukemia, West London M. J. 25" 91, 1920.
Brie[ clinical and laboratory observations
4 65
2. Thompson, J. H., and Posel, M. M.: A case of intussusception in in acute lymphatic leukemia, Lancet 218, 1180, 1930. 3. Smith, N. J., Vaughan, V. C., and Diamond, L. K.: The leukemias, in Nelson, W. E.: Textbook of pediatrics, ed. 7, Philadelphia, 1959, W. B. Saunders Company, p. 966.
Water intake of normal children Abstract. Estimates o[ daily total fluid intake and o[ tap-water consumption o[ normal children were made in [our dissimilar geographic areas in the United States. (Total fluid intake, increased and, relatively speaking, tap-water consumption decreased, with age.) O[ basic importance in fluoridation programs was the observation that even older children rarely drank as much as 500 ml. (about 1 pint) o[ tap-water daily. (From Science 140: 3569, 1963.)
Number 3
Brie[ clinical and laboratory observations
4 6 3
aerator p u m p +~ m o u n t e d in a plywood a n d h a r d w a r e - c l o t h box to keep fingers out of the machinery. These p u m p s are assembled to deliver positive pressure. T h e i r valves are easily reversed to convert t h e m to suction.
OPERATION W h e n connections are complete, the p u m p is started a n d operates continually. This results in constant suction and airflow t h r o u g h the system. W h e n the baby voids, urine is rapidly sucked from the cup a n d t r a p p e d in the bottle. Occasionally urines are needed from uncooperative or unconscious older children. F o r them, the b o t t o m is cut from a s t a n d a r d plastic urine collector a n d this is a t t a c h e d to the cup with adhesive. T h e soft plastic collector is then fixed to the perineum as usual. T h e device facilitates nursing care of the infant. H e can be h a n d l e d rather freely for feeding, bathing, and dressing. U n d o u b t e d l y , the use of a m e c h a n i c a l device adds enough "busyness" to the p r o c e d u r e to remind tile attendants that something i m p o r t a n t is going on.
Fig. 1. plastic tube connects the cup to a length of glass tubing in a two-hole stopper fitted to tile collection bottle. This inlet should extend into the bottle an inch or so beyond the orifice of the suction tube.
THE P U M P A similar suction tube, connected to the outlet of the collecting jar, is taken to the p u m p (B). T h i s is an inexpensive a q u a r i u m
--,ntmsusceptwas n a cause ro] death in acute leukemia
Report of a
case
Bernard H. Feldman, Lieutenant (MC) USN, and F r e d e r i c A. Schulaner, L i e u t e n a n t ( M C ) U S N
CASE R E P O R T
H • ~a o R R H A G E ~ a universal occurrence in leukemia, is often responsible for the patient's death. W e present an instance where h e m o r r h a g e p l a y e d an unusual role in the patient's clinical course.
A 5-year-old Caucasian female was admitted initially to the United States Naval Hospital, Bethesda, Md., in June, I961, with a mass in the scalp. The diagnosis of lymphosarcoma was
From the United States Naval Hospital, Bethesda 14, Md. The opinions expressed herein are those o/the authors and do not reflect necessarily the views o[ the Navy Departraent.
~Glo-Lite "Jet-88" Aerator, Model 1010, Glo-Lite Manufacturing Company, 117 East 129th Street, New York 35, N. Y. has worked well.
4 64
Brief clinical and laboratory observations
September 1963
A-C Fig. 1. A, Gross specimen of intussuscepted bowel with proximal end to the right. B, Crosssection of (A) showing intramural hematoma at apex of intussusceptum. C, Photomicrograph of intussuscepted bowel. made by excisional biopsy and postoperative irradiation was administered. She did well until November, 1961, at which time she developed acute lymphoblastic leukemia. During the following 4 months, she was treated with 6-mercaptopurine and, when relapse occurred, received a folic acid antagonist~; steroids were used intermittently when bleeding was severe. Her final admission in August, t962, occurred because of the progressive development over a 3 day period of abdominal pain, abdominal distention, constipation, and somnolence. The patient was febrile, lethargic, and cried out occasionally as if in pain. The abdomen was tense, tympanitic, free of masses other than an enlarged liver and spleen, and there was a paucity of bowel sounds. Petechiae were minimal in number. The white blood count was 4,490 per cubic millimeter with a shift to the left in the white blood count; the lymphoblasts numbered 1 per cent. The hemoglobin level was 11.2 Gm. per 100 ml.; the platelet count was 11,000 cubic millimeter. The bone marrow was hypercellular and showed marked lymphoblastic proliferation. Spinal fluid examination was unremarkable. Coliform bacilli were found by blood culture. An upright roentgenogram of the abdomen demonstrated fluid levels. Gastric suction, antibiotic therapy, and supportive measures were used but the patient lived less than 48 hours, during which time neither decompression of the bowel nor return of bowel sounds occurred. No blood was passed per rectum. At autopsy, multiple ecchymoses of the small bowel were present as well as four areas of intussuscepted ileum. From their appearance, it was evident that the intussusceptions occurred ante-mortem. Most of the intussuscepted bowel was gangrenous. On cut section, it was noted that ~Methotrexate, manufactured by Lederle Pearl River, N. Y.
Laboratories,
an intramural hematoma was the leading point of each intussusceptum (Fig. 1). DISCUSSION Intussusception in association with leukemia has been reported only rarely?' ~ I n what appears to be the first documented case, 1 a polypoid mass i n the upper ileum was found at the apex of an intussusception. Microscopic e x a m i n a t i o n revealed hyperplasia of lymphoid tissue. I n the case recorded by T h o m p s o n a n d Posel, 2 and in our own, an i n t r a m u r a l h e m a t o m a of the small bowel provided a leading point for peristaltic invagination. Except in infancy, an exciting factor is usually found as a cause of the intussusception. O f t e n this exciting factor m a y be a tumor. L e u k e m i a can produce such a tumor' either by lymphocytic infiltration a n d hyperplasia of a polypoid n a t u r e or by intram u r a l extravasation of blood with the formation of hematomas. A b d o m i n a l p a i n is a rather c o m m o n occurrence in leukemia and has been explained by extensive e n l a r g e m e n t of the abdominal l y m p h nodes? These cases would suggest that intussusception should be classified as a rarer cause of a b d o m i n a l pain in acute leukemia as well as one of the m a n y ways in which h e m o r r h a g e m a y present. SUMMARY
A 5-year-old, leukemic child with intussusception as the immediate cause of death is described. T h e association of these two conditions is extremely rare, b u t it
Volume 63 Number 3
would a p p e a r that intussusception m a y be the result of i n t r a m u r a l intestinal hemorrhage resulting from acute leukemia. REFERENCES
1. Sinclair; N.: Intussusception complicating lymphatic leukemia, West London M. J. 25" 91, 1920.
Brie[ clinical and laboratory observations
4 65
2. Thompson, J. H., and Posel, M. M.: A case of intussusception in in acute lymphatic leukemia, Lancet 218, 1180, 1930. 3. Smith, N. J., Vaughan, V. C., and Diamond, L. K.: The leukemias, in Nelson, W. E.: Textbook of pediatrics, ed. 7, Philadelphia, 1959, W. B. Saunders Company, p. 966.
Water intake of normal children Abstract. Estimates o[ daily total fluid intake and o[ tap-water consumption o[ normal children were made in [our dissimilar geographic areas in the United States. (Total fluid intake, increased and, relatively speaking, tap-water consumption decreased, with age.) O[ basic importance in fluoridation programs was the observation that even older children rarely drank as much as 500 ml. (about 1 pint) o[ tap-water daily. (From Science 140: 3569, 1963.)