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Infectious complications and symptomatic therapy of an acute leukosis - Practical hematology of children's age

Table of contents
Practical hematology of children's age
Embryonal hemopoiesis
Morfofunktsionalny characteristic of cells of marrow and peripheral blood
Marrow parenchyma cells
Peripheral blood of children of different age
The system of a hemostasis is normal
Etiology and pathogeny of leukoses
Acute leukoses
Acute leukoses - a preleukosis
Possibilities of a predictive assessment of a course of an acute lymphoblastoid leukosis at children
General principles of treatment of an acute leukosis
Chemotherapeutic drugs
Treatment of an acute lymphoblastoid leukosis
Treatment of myeloid forms of an acute leukosis
Infectious complications and symptomatic therapy of an acute leukosis
Consolidation and maintenance therapy of an acute leukosis
Immunotherapy
Remission and recurrence of an acute leukosis
Inborn leukosis
Neuroleukosis
Myelosis
Lymphogranulomatosis
Gematosarkoma
Macrofollicular lymphoma
Angioimmunoblastny lymphadenopathy
Leukemoid tests
Infectious lymphocytosis
Infectious mononucleosis
Leukemoid tests of different types
Dysfunctions of granulocytes
Leukopenias
Histiocytoses
Histiocytoses - an eosinophilic granuloma
Malignant histiocytosis
Family erythrophagocytal histiocytosis
Accumulation diseases
Nimann's illness — Peak
Angiopathies
Hemorrhagic vasculitis (Shenleyn's illness — Genokh)
Mayokki's purpura
Ataxy teleangiectasia
Entsefalotrigeminalny angiomatosis
Kortiko-meningealny diffusion angiomatosis
Cerebroretinal angiomatosis
Hypertrophic gemangiektaziya
Multiple and huge hemangiomas
Elastic fibrodisplaziya
Coagulopathies
Hereditary coagulopathies
Hemophilia And
Clinic of hemophilia
Treatment of hemophilia
Angiohemophilia
Cristmas disease (Kristmas's illness)
Hereditary deficit of factors of XI, XII, XIII and I
Dysfibrinogenemias
Hereditary deficit of factors of VII, X, V and II
Deficit K-vitaminozavisimykh of factors of coagulation
Syndrome of the disseminated intravascular coagulation
Clinic and diagnosis of the IDCS
Treatment of the IDCS
Thrombocytopenia
Idiopathic Werlhof's disease
Clinic and diagnosis of an idiopathic Werlhof's disease
Treatment of an idiopathic Werlhof's disease
Isoimmune Werlhof's disease
Transimmune Werlhof's disease of newborns
Trombogemolitichesky Werlhof's disease (syndrome Moshkovich)
Hereditary Werlhof's diseases
Trobotsitopatiya
Anemias
The anemias connected with blood loss
Chronic posthemorrhagic anemia
Iron deficiency anemias
Clinic and diagnosis of an iron deficiency anemia
Treatment of iron deficiency anemias
Sideroakhrestichesky, sideroblastny anemias
Megaloblastny anemias
Foliyevodefitsitny anemia
Hereditary forms of megaloblastny anemias
Hereditary dizeritropoetichesky anemias
The anemias connected with oppression of proliferation of cells of marrow
Hereditary hypoplastic anemias
Hemolitic anemias
Hemolitic anemias - an ovalocytosis, a hereditary stomatocytosis
Acanthocytosis, piknotsitoz
The hereditary hemolitic anemias connected with disturbance of activity of enzymes of erythrocytes
The hereditary hemolitic anemias connected with disturbance of structure or synthesis of hemoglobin
The acquired immune hemolitic anemias
Isoimmune hemolitic anemias
Treatment of a hemolitic illness of newborns
Autoimmune hemolitic anemias
List of references

The basic chemotherapy applied separately cannot provide the maximum effect. During induction therapy an important task is prevention and treatment of the complications able to become the reason of a lethal outcome. One of them — infectious complications. L. G. Kovalyova (1978) considers infectious complications as the states caused by cytostatic therapy. The analysis of statistical data demonstrates that with increase in longevity of patients the frequency of infectious complications increases several times.
Allocate two main pathogenetic links causing emergence of infectious and inflammatory complications. First, they develop against the broken immune responsiveness of an organism. Decrease in immunological protective forces of an organism is connected both with specifics of the developing leukemic process, and with immune depressive actions of chemotherapy. And immunological defects are observed in all links of nonspecific reactivity. There are disturbances in a humoral link of immunity. Cytostatic therapy leads to decrease in concentration of immunoglobulins. However at development of infectious process proper response is noted and the level of immunoglobulins increases. The most considerable disturbances of humoral factors of immunity are connected with decrease in level of R-lysines, bactericidal in relation to gram-positive flora. At acute leukoses, irrespective of option and the period of an illness, the level of R-lysines is reduced more than twice (T. V. Golosova and soavt., 1974). At patients with an acute leukosis during development of pyoinflammatory processes of skin decrease in concentration of a lysozyme in blood serum is also noted. The amount of the enzyme in saliva playing an important role in local immunological protection of mucous membranes of an oral cavity and a nasopharynx in the presence of ulcer and necrotic defeats decreases by 2 — 3 times (V. A. Martynova and soavt., 1975). Certain features in the maintenance of other nonspecific humoral factors of an immune responsiveness of an organism are revealed: S-reactive protein, properdin, complement, interferon. In development of infectious and inflammatory complications an important role is played by deficiency of a cellular link of immunity. At acute leukoses considerable decrease in phagocytal ability of granulocytes is noted (neutrophylic and monocytes). Irrespective of a stage of process a physical activity, the absorption and digesting abilities of cells are broken. Decrease of the activity of a cellular link of immunity is connected also with disturbance of functional capacities of the lymphocytes which are aggravated in the course of cytostatic therapy.
The second pathogenetic mechanism promoting development of infectious and inflammatory complications are the pancytopenia and an agranulocytosis. The agranulocytosis is to a lesser extent caused by tumoral process (suppression by blast cells of normal sprouts of a hemopoiesis) and in bigger — effect of cytostatic drugs. Especially brightly it is shown during the patient's exit in remission which indispensable condition is the medicinal hypoplasia of a marrowy hemopoiesis.
Such background of an organism causes easy development of infectious processes at an acute leukosis. According to different authors, the frequency of infectious complications reaches 75%. Most often the course of leukemic process is complicated by pneumonia, ulcer and necrotic damage of a digestive tract, purulent diseases of skin and a hypodermic basis. Features of a children's organism promote fast generalization of an infection and development of sepsis.
Infectious complications meet identical frequency at acute lymphoblastoid and acute miyeloblastny leukosis options, however in the latter case they proceed much heavier. Immunological insufficiency of an organism defines a number of features of emergence and the course of infectious and inflammatory processes. Oredi of the etiological reasons first place is won by not exogenous, but endogenous flora of an organism. Opportunistic microorganisms leave izpod immune control, become more active and cause a disease. Results of numerous researches demonstrate that in development of infections the bacterial gram-negative flora (60 — 80%) has the greatest value: sticks pyocyanic, intestinal, ozenas. Less often infection with Proteus and salmonellas meets. Specific weight (to 20%) fungal infections is high: candidiases and aspergillomycosis. Among gram-positive microorganisms (10 — 20%) first place is won staphylococcus, the role of streptococci increases.
The role of a viral infection is small (to 10%). And enteroviral, miksovirusny, adenoviral, rinovirusny infections do not give complications and proceed usually. Influence the course of leukemic process of an infection much heavier, caused by viruses of hepatitis, a herpes simplex, chicken pox, shingles, measles, a cytomegalovirus. Prevalence and contageousness of children's infectious diseases poses threat for patients with acute leukoses. The chicken pox and measles complicating the course of the main process cause a lethal outcome even during full kliniko-hematologic remission. Preventive inoculations as even vaccination by avirulent virus drugs can cause generalization of an infection are categorically contraindicated to such children.
Without going into details of the description of a clinical picture of infectious and inflammatory complications, we will list the main of them: 1. Infectious defeats of respiratory system — bronchitis and pneumonia. Abscessing and purulent pleurisy are possible that it can be also caused by a septicopyemia. 2. Sepsis — septicemic and septicopyemic forms. 3. Pustulous damages of skin and hypodermic basis. As manifestation of a septicopyemia, and also phlegmon, abscess, a furuncle, an anthrax, a felon, a paraproctitis etc. 4 separately meet. Infectious diseases of a digestive tract — stomatitis, an ulitis, ulcer and necrotic damages of mucous membranes, enteritis, a coloenteritis. 5. The viral infections which are characterized by process generalization. The herpes simplex can affect extensive sites of skin, mucous membranes of a digestive tract. 6. Fungal infections also tend to process generalization, affecting lungs, a digestive tract, the central nervous system. 7. Infectious and inflammatory processes of other localizations: purulent otitis, intermuscular abscesses, osteomyelitis, quinsy, acute pyelocystitis.
Emergence of infectious process matches development of a pancytopenia and agranulocytosis, falling of an immune responsiveness of an organism at height of cytostatic therapy. As a rule, infectious and inflammatory complications appear without manifest signs. The current is characterized by a smoothness and an atipizm of a clinical picture. Early diagnosis is complicated as process develops gradually, there are no general symptoms of inflammatory diseases — disturbance of the general state, temperature reaction etc. The general background — immunological deficiency of an organism — promotes fast generalization of process with defeat of several bodies and systems.
Many authors point to complexity of early and differential diagnosis of infectious complications. Quite often the first symptom of an infection — — it is difficult to otdifferentsirovat temperature increase from possible reaction to chemotherapy, a hemotransfusion. Nevertheless any temperature increase even if the disease center is not revealed, indicates development of infectious process and demands immediate treatment. Therapy of infectious and inflammatory complications of an acute leukosis is extremely difficult and in some cases it can be inefficient. Therefore it is necessary all efforts to concentrate on prevention of infections.
Measures of prevention are especially important in the presence of a cytopenia and shall be undertaken at patients with the level of leukocytes 1 X 109/l. Isolation and creation of the greatest possible aseptic conditions is for this purpose reasonable. Are for this purpose necessary: daily processing of the room disinfecting solutions, ultra-violet radiation, change of linen, observance by personnel of rules of an asepsis. The maximum cleansing of skin and mucous membranes at the patient. At impossibility of daily bathtubs disinfection of skin and mucous membranes of an oral cavity, a nasopharynx is carried out by various solutions. Careful processing of cracks, scratches, places of pricks. For the purpose of prevention appoint inside antibiotics of a broad spectrum of activity — Oxacillinum, ampicillin, Oletetrinum. For suppression of endogenous flora carry out sterilization of guts by not adsorbing drugs — polymyxin in combination with antifungal antibiotics — nystatin. Apply easy purgatives. At the children having an acute leukosis in the period of a granulocytopenia (quantity of neutrocytes less than 0,75 X 109/l) inhalations by a lysozyme apply to prevention of pneumonia, along with antibiotics.
As it was already noted, temperature increase at such patients is regarded as accession of infectious process that dictates need of cancellation of a preventive course of antibiotics and the beginning of a massive antibioticotherapia. Before establishment of the nature of the activator appoint parenterally combinations of antibiotics of a broad spectrum of activity in the maximum therapeutic doses. Use of semi-synthetic penicillin (Methicillinum, Oxacillinum, ampicillin, ampioks) with antibiotics of aminoglikozidny group is possible (gentamycin). The combination possesses a wide antibacterial range, but poorly affects a pyocyanic stick. The combination of the karbenitsillin influencing a pyocyanic stick to gentamycin is optimum. The effect can be strengthened, adding one more antibiotic from group of a reserve (tseporin, Kefzolum, Cefamezinum). At decrease in temperature in the first days treatment is continued by the same complex of antibiotics. In the absence of visible results it is necessary to appoint drugs on character of the allocated activator. The pyocyanic stick is sensitive to a karbenitsillin, gentamycin, a tseporin. At an infection colibacillus apply Kanamycinum, ampicillin, gentamycin, tseporin. Therapy of the infections caused by gram-positive flora, including staphylococcal is carried out by penicillin, semi-synthetic penicillin in combination with aminoglycosides (gentamycin). At a refrakternost to an antibioticotherapia it is necessary to assume a fungal infection. Fungal complications are treated by nystatin, at damage of internals — parenteral drug Amphotericinum of Century. In need of a combination therapy use penicillin and its derivatives, erythromycin, Oleandomycinum in combination with nystatin. The drugs possessing at the same time antibacterial and antifungal action are shown: Enteroseptolum, Mexaformum, Intestopanum, 5-HOK, also in combination with nystatin. For topical treatment of candidiases aniline dyes are recommended: methylrosanilinum chloride, pioktatin, main fuchsin, malachite greens (1% aqueous solutions). Frequent rinsings of an oral cavity and a throat are recommended by aqueous solutions (1: 1000) aniline dyes, iodide water (5 — 10 drops of 5% of solution of iodine spirit on a glass of water).
At viral infections for prevention of consecutive infection use Oxolinum, interferon, specific gamma-globulins in combination with antibiotics.
Complex treatment of infectious and inflammatory complications includes the actions directed to increase of immunological forces of an organism, and means of replacement therapy (differentiated, transfusions leucio-and trombomassa). In certain cases appoint direct hemotransfusions, use of different types of gamma-globulins is shown.
At pyoinflammatory diseases of skin and a hypodermic basis carry out surgical intervention.
During infectious complications if the deep pancytopenia does not develop, it is necessary to continue antileukemic treatment against intensive symptomatic care.
The final effect of chemotherapy depends on that, fight against noninfectious complications is how successful. It is important not to lose the child, having taken all measures of prevention of cardiovascular insufficiency, an acute renal failure, intoxication, metabolic disturbances. The chemotherapy is effective in those cases if it is carried out against compensation of the main functions of an organism. Disintoxication therapy by intravenous drop administration of low-molecular drugs is for this purpose necessary: Haemodesum, Neocompensanum, glyukozo-saline solutions. For correction of metabolic disturbances appoint glyukozo - insulin and potassium mix, bicarbonate sodium solution. Maintenance of cardiovascular activity is provided, using cardiac glycosides. From them Korglykonum, strophanthin are high-speed. At the acute leukosis which is especially proceeding with a hyperleukocytosis as a result of massive disintegration of tumor cells under the influence of chemotherapy development of a hyperuricemia and urate nephropathy is possible. For prevention of these complications appoint Allopyrinolum (Miluritum). If the scheme of therapy of an acute leukosis includes 6 Mercaptopurinum, its dose is reduced twice as Allopyrinolum strengthens toxic action 6 Mercaptopurinums. Plentiful administration of liquid inside and parenterally (isotonic solution of sodium of chloride, glucose), Natrii hydrocarbonas is necessary (for correction of giperurikemichesky acidosis).



 
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