Edema with leukemia
Early objective symptoms of acute leukemia in children are diverse. The most frequently observed increase in lymph nodes, pain in the bones and joints, hemorrhagic manifestations.
It should be borne in mind that the increaseperipheral lymph nodes may be different. Often knots are small, but sometimes reach the size of a hen's egg and more; in a number of cases, patients may already have an increase in the lymph nodes of the mediastinum at the beginning of the disease. These symptoms often give rise to an erroneous diagnosis: chronic tonsillitis. tuberculosis. infectious mononucleosis. lymphogranulomatosis. lymphosarcoma, etc. Timely study of peripheral blood and bone marrow punctate in many cases helps to establish the correct diagnosis.
In addition to bone marrow puncture, with enlarged lymph nodes, the puncture is also indicated for diagnostic purposes.
The second, often observed, symptom in the initialthe period of acute leukemia is pain in the bones and joints. They can give rise to the diagnosis of rheumatism. infectious polyarthritis. brucellosis, etc. In these cases, in order to diagnose, in addition to the study of peripheral blood and bone marrow punctate, an X-ray examination is necessary, which already at early stages of the disease can reveal changes specific for leukemia (destructive changes in bone tissue). According to the instructions of DN Yanovsky, most of the acute leukemia begins with an angina. VM Novodvorskiy in 25% of patients noted angina in the initial period of the disease. In children, angina as an early symptom is much less common. In many patients, leukemia begins with nasal and alveolar bleeding, hemorrhage into the skin, mucous membranes, the appearance of blood in the excrements. These symptoms of hemorrhagic diathesis, observed in other diseases (Verlhof's disease, hemophilia, hemorrhagic vasculitis scorbut, aplastic and hypoplastic anemia, etc.) also often lead to an erroneous diagnosis.
For differential diagnosis of leukemia withhypoplastic anemia, in addition to the study of blood and bone marrow puncture, currently the method of trepanobiopsy is successfully applied. This method consists in removing a piece of bone tissue from the iliac crest with a special trepan needle.
In the study of trepanates taken from patientsleukemia and hypoplastic anemia, certain differences are revealed. At a hypoplastic anemia, especially at transition to aplasticheskuju a phase, the picture of the expressed devastation with replacement of a hemopoietic tissue fat is observed. While in leukemia, even in leukopenic form, there is hyperplasia of the hematopoietic system. However, it is necessary in each case to take into account the nature of the course of the process and the phase of the development of the disease. So, in the initial phase of hypoplastic anemia in trepanate there is no pronounced devastation. Conversely, in some variants of acute and chronic leukemia, especially treated with antimetabolites, and sometimes without treatment, the picture of trepanate is similar to devastation (fat substitution, fibrosis areas).
The study of the initial period of acute leukemiaallows to establish that in children the character of development of early symptoms is not the same. In some cases, the early symptoms of the disease, having appeared and continuously increasing, give a detailed picture of the disease, in others - these symptoms, having existed for a while, disappear. So there comes a latent period, during which the disease can be detected only when examining blood and bone marrow punctate. Then generalized development of the disease occurs.
In patients with acute leukemia,pallor of the skin, which rarely have a jaundice, and sometimes a grayish hue. There are frequent rashes of hives. herpes. Often there are hemorrhages in the skin and mucous membranes.
In the initial period of leukemiaThe spleen does not reach large sizes and is often palpable at the rib margin, being elastic and painless. In the future, it can progressively increase, which is observed in 60-70% of patients. In the period of unfolded phenomena, the spleen was increased in almost all patients; the liver is enlarged in 80-90% of patients, but it does not reach large sizes, it can be painful.
From the cardiovascular system already inthe initial phase of the disease is systolic murmur at the apex, a slight expansion of the border of the heart, tachycardia. All this fits into the notion of an "infectious heart", which also depends on intoxication. It should be added that patients have a tendency to hypertension.
Changes in the respiratory system in the initialperiod of the disease are insignificant. Only very rarely patients have bronchitis and pneumonia. Sometimes symptoms associated with necrotic damage to the respiratory tract (rough barking cough, labored breathing, false cereal) are noted. Significant changes in the lungs associated with a specific lesion of them occur later.
A variety of clinical symptoms from the sidegastrointestinal tract are mainly associated with intoxication: decreased appetite, nausea, vomiting, sometimes abdominal pain, feigning diseases that require surgical intervention (appendicitis invagination). Occasionally, patients will find blood in the stool, which gives reason to suspect dysentery.
In addition to the general symptoms of the nervous system mentioned above, paresis and paralysis can sometimes occur in the initial period of the disease.
The course of the initial period of the diseaseWave: periods of relative well-being are followed by periods of exacerbation. Without treatment, the initial period passes into the period of full development of the disease, when there is a whole symptom complex of the disease. Gradually, the patient's condition worsens. With subacute current leukemia in children, a satisfactory state of health may last for a long time. In a rapidly developing process, a state of severe toxicosis quickly sets in: children hardly rise from bed and react weakly to the environment.
The temperature curve for acute leukemia isundulating character. The majority of patients in the period of full development of the disease have a pronounced temperature response (60% of patients), and only a few have normal temperatures. The degree of temperature reaction depends on the severity of the flow of the process. A sudden rise in temperature in patients with acute leukemia is an unfavorable sign, indicating an onset of exacerbation of the process or the transition of the disease to the terminal phase.
The main clinical symptoms of acute leukemia in children are: enlargement of the spleen and lymph nodes, hemorrhagic phenomena.
Necrotic lesions of the skin and mucous membranes thatpreviously observed very often, now with leukemia are very rare in the period of unfolded phenomena and are found only in the terminal phase of the disease.
The size of the spleen depends on the nature of the flowprocess and applied therapy. In acute leukemia, in contrast to the chronic form of the disease, the spleen is very rarely dense. Its function is of great diagnostic value, as in this case, as a rule, leukemia metaplasia is found.
The size of the lymph nodes is different: at first they have the size of a pea, and then can reach the size of a chicken egg and more. Most often all groups of lymph nodes are enlarged. Characteristic of their symmetrical arrangement, but sometimes the lymph nodes are asymmetrically, and then the patients resemble children suffering from lymphogranulomatosis. Puncture of lymph nodes also has great diagnostic value, since it often reveals leukemia metaplasia. Suppuration of lymph nodes with the formation of fistula almost does not happen.
Pathomorphological examination of the tumor more oftenreveals an increase in leukemia infiltrated thymus gland, soldered with leukemia infiltrated mediastinal tissue, and less frequent enlarged lymph nodes of the mediastinum. Sometimes there is a combination of an enlarged thymus gland and hyperplastic mediastinal lymph nodes. Differential diagnosis of acute leukemia, which occurs with a mediastinal tumor, from lymphosarcoma and lymphogranulomatosis presents great difficulties. Perhaps this is due to the various names of this form of the disease: Sternberg called it leukosarcoma, Pappenheim - sarcoleukemia, IA Kassirsky and NA Kraevsky consider these forms pathogenetically related.
The greatest difficulties for diagnosis arecases of acute leukemia with an "isolated" tumor of the mediastinum, which is determined in some cases earlier than there are changes in peripheral blood and puncture of the bone marrow, indicative of the leukemic nature of the disease.
In addition to the characteristic radiographic picture,a tumor that has reached a large size, gives symptoms of compression of the airways, and sometimes displacement of the mediastinum, which can threaten the life of the patient. When the child is examined, a chest swelling, an expansion of the venous network on the chest, edema of the jugular fossa, neck, face, shortness of breath and a rough barking cough are detected. Children complain of pain in the heart, giving in the left arm, and a feeling of pressure in the chest. But sometimes there are "dumb" tumors that last for a long time do not make themselves felt and are detected during an accidental examination.
Hemorrhagic syndrome is one of the most strikingand evidence of leukemia in children. Patients with hemorrhages in the skin, mucous membranes, nosebleeds, gums, hematuria, hemorrhages in the brain and the middle ear. All these numerous variants of bleeding give a diverse clinical picture. The pathogenesis of hemorrhagic syndrome is complicated. Undoubtedly, the factor of the defeat of the vascular wall, anoxemia, thrombopenia, etc., is important.
In recent years, when studying the blood coagulation system and hemostasis processes, certain violations of these processes in leukemia have been revealed.
The Institute of Pediatrics of the Academy of Medical Sciences conducted a study of the state of the coagulating system of blood in children suffering from leukemia. The following is revealed.
1. Recalcification time, i.e., the time of conversion of fibrinogen plasma into fibrin, in the majority of children with leukemia is significantly slowed down and reaches in some cases 32-51 minutes, especially in patients with a pronounced hemorrhagic syndrome.
2. Tolerance to heparin does not give large deviations from the norm.
3. Reduction of prothrombin, as a rule, was observed in all patients and reached 29%. In the period of remission, it rose to 100-110% or more.
4. The consumption of prothrombin in the process of blood coagulation in all patients was reduced and reached 8%. The decrease and increase in the consumption of prothrombin went in parallel with the clinical symptoms: during the remission it increased, during the exacerbation - it decreased.
5. The content of fibrinogen was subjected to large fluctuations (from 64-99 to 618 mg%), the formation of fibrin was slowed down.
6. Retraction of the blood clot in most patients is reduced (0.2-0.15).
7. The bleeding time is much longer, sometimes up to 30 minutes.
Liver in acute leukemia in children is also often increased. The enlargement of the liver is often accompanied by painful sensations due to the expansion of the capsule.
As already mentioned above, one of the earliest and inFurther persistent symptoms are pain in the bones and joints. X-ray examination usually reveals osteoporosis, osteosclerosis, periosteal reaction, destructive changes from very minor to destruction of bone tissue, accompanied by fractures of bones. Specific lesion of the spine is described in children with leukemia - breezepondylia, expressed in diffuse osteoporosis of vertebral bodies, in the reduction and flattening of their spines and a significant increase in the height of the intervertebral discs. Clinically, breezepondylia is manifested by pains in the spine, later the patients stop walking and sitting.
When pathomorphological examination of bonesare detected: leukemia infiltration, rarefaction of bone tissue, degeneration. In connection with the fact that the destruction in the bones of patients is significant, it is necessary to differentiate leukemia with myeloma, sympathogony, osteo- and myelosarcoma.
In the period of unfolded phenomena, changesfrom the heart: systolic murmur on the apex, and sometimes on the aorta, widening of its borders, tachycardia. In this period, in addition to the effects of intoxication on the cardiovascular system, degenerative changes in the myocardium are important in connection with hypoxemia, leukemia infiltration and hemorrhages. Sometimes there is an arrhythmia.
Symptoms of nervous system damage can bedivided into general and local. Common symptoms: headache, agitation, drowsiness, lethargy, delirium, hallucinations. All of them are caused by intoxication, anemia, oxygen starvation and an adherent cerebral circulation disorder.
Local symptoms are caused by compression andgrowth in the nervous tissue of the foci of leukemia metaplasia, as well as hemorrhage into various parts of the brain. Sometimes symptoms of compression are observed, depending on the defeat of the bones of the skull and spine (neuralgia, neuritis, paresis, paralysis, visual and hearing impairment).
With leukemia, children have recently been identifiedspecific lung lesions, diffuse leukemia infiltration of the walls of alveoli and alveolar courses and pneumonitis - thickening of the alveolar wall and proliferation of elastic fibers in it, swelling and homogenization of alveolar walls. Clinically, these changes are very meager: the temperature is normal, in the lungs - areas of shortening of percussion sound with the presence of wet rales of various calibers, sometimes dry wheezes. Often, patients experience shortness of breath and cyanosis. In the radiographic examination of the lungs, large, small or dense foci of darkening, sometimes of a milder form, resembling a billion tuberculosis or the Beck sarcoid are found. Rarely, against the background of leukemia infiltration, a cavity similar to a cavern with tuberculosis is found. Cases of specific leukemic pleurisy with the presence of hemocytoblasts in exudate are described. Nonspecific lung lesions in leukemia occur more often in the terminal phase of the disease.
In the period of full development of the disease in children, oftenthere are increasing changes in the digestive system: a decrease in appetite, nausea, vomiting, diarrhea. Sometimes there are sharp pains in the abdomen, reminiscent of appendicitis or intestinal obstruction. With pathomorphological examination, foci of leukemia infiltration, hemorrhages, edema of solitary follicles and Peyer's patches and various degrees of necrosis are usually found. Especially dangerous are ulcerative necrotic processes. Pain in the abdomen of children can occur as a result of compression of individual parts of the gastrointestinal tract with enlarged lymph nodes.
A rare sign of leukemia is gingivitis. The expressed pallor of the skin and mucous membranes depends on the growing anemia. In addition to changing the color of the skin, patients sometimes have different lesions: dense hemorrhagic infiltrates, pemphigoid blisters, exudative erythema. hives. Very speckled rashes on the palms. Skin and mucous patients who are not receiving treatment are covered with hemorrhages.