Leukaemia: Is a cancer of the blood or bone marrow and is characterized by an abnormal
proliferation (production by multiplication) of blood cells, usually white blood cells
(leukocytes).
Leukemia is clinically and pathologically subdivided into several large groups. The first
division is between its
Acute leukemia
Chronic leukemia
Acute Leukaemia
Acute leukemia is characterized by the rapid increase of immature blood cells or blasts
in the bone marrow
This crowding makes the bone marrow unable to produce healthy blood cells
Immediate treatment is required in acute leukemia due to the rapid progression and
accumulation of the malignant cells, which may then spill over into the bloodstream and
spread to other organs of the body
Death usually occurs within 6 months in most patients
Acute forms of leukemia are the most common form of leukemia in children.
Chronic Leukaemia
Chronic leukemia is distinguished by the excessive build-up of relatively mature, but still
abnormal, white blood cells.
Typically taking months or years to progress, the cells are produced at a much higher rate
than normal cells, resulting in many abnormal white blood cells in the blood.
Compared to acute leukemia which must be treated immediately, chronic forms are
sometimes monitored for some time before treatment to ensure maximum effectiveness of
therapy.
Chronic leukemia mostly occurs in older people, but can theoretically occur at any age
group. Acute and chronic leukemia are further classified according to their cell
lineage into two major categories, namely
Myeloid
Lymphoid
Thus acute leukemia may either be
Acute myeloblastic leukemia (AML) or
Acute lymphoblastic leukemia (ALL)
Chronic leukemia may either be
Chronic myeloid leukemia (CML) or
Chronic lymphocytic leukemia (CLL)
Four Major Kinds of Leukaemia
Cell Type Acute Chronic
Lymphocytic leukemia
(lymphoblastic)
Acute lymphoblastic
leukemia (ALL)
Chronic lymphocytic
leukemia (CLL)
Myelogenous Leukemia
(Myeloid)
Acute myeloblastic
leukemia (AML)
Chronic myeloid leukemia
(CML)
Risk Factors and Epidemiology of Leukemia
Risk Factors
In majority of patients the causes of leukemia is unknown
Several factors are however associated with the development of leukemia and these
include
Ionizing radiation
Cytotoxic drugs
Exposure to benzene in industry
Retroviruses- human T-lymphocytic virus
Genetic
Immunological causes
Epidemiology
Acute leukemia occur at all ages
Acute lymphoblastic leukemia (ALL) shows a peak of incidence in the 1-5 age group
All forms of acute myeloid leukemia (AML) have their lowest incidence in young adult
life and there is a striking rise over the age of 50 years.
Chronic leukemia occurs mainly in middle and old age
Clinical Features of Leukaemia
Clinical features manifest due to
Infiltration & replacement of normal bone marrow with leukemic cells resulting into
Anemia
Neutropenia
Thrombocytopenia
Infiltration of other tissues & organs with leukemic cells-liver spleen and lymph
nodes.
Increased metabolic rate when the tumor mass is large.
Patients with anemia may present with
Easy fatigability
Shortness of breath
Palpitation
 Weakness
Lassitude
Patients with neutropenia may be prone to bacterial infections (particularly pneumonia &
septicemia) from:
Gram negative bacteria such as
Escherichia coli
Klebsiella spp
Pseudomonas auregenosa
Gram positive bacteria such as
Staphylococcus aureus
Staphylococcus epidermidis
Patients with leukemia may also have decreased immunity that may predispose them to
opportunistic infections (OIs) such
Fungal infections (e.g. candidiasis and aspergillosis)
Pneumocystis pneumonia (PJP/PCP)
Herpes simplex
Herpes zoster (shingles)
Patients with thrombocytopenia may present with
Petechiae hemorrhages
Epistaxis (bleeding from the nose)
Bleeding from the gums
Spontaneous bruising
Eye & internal ear-bleeding (depends on the extent of the disease)
Leukemia may also lead to increased basal metabolic rate (BMR) that may manifest with
excessive sweating and loss of weight.
Clinical Features of Acute Leukaemia (ALL & AML)
Patients are usually ill-looking
Symptoms and signs develop over days or a couple of weeks. The presentation may
include the following
Pallor
Fever
Various infections
Abnormal bleeding
Painful & tender bones especially in ALL
Hepatosplenomegaly (enlargement of liver and spleen)
Enlargement of lymph nodes in ALL is not uncommon
Meningeal infiltration (mostly in ALL) leads to
Headache
Nausea
Vomiting
Visual disturbance
Clinical Features of Chronic Leukaemia (CLL & CML)
Patients with chronic myeloid leukemia (CML) may have the following features
Tiredness
Weight loss
Breathlessness
Abdominal pain & discomfort in about 90% of patients
Lethargy
Anorexia
Night sweating
Abdominal fullness
Bruising, low-grade fever, & palpitation
The principal clinical finding is splenomegaly in 90%, and about 10% have massive
splenomegaly
Hepatomegaly in about 50% of patients
About 25% of patients are asymptomatic at diagnosis
Note: Lymphadenopathy is unusual
Clinical Features of Chronic Lymphocytic Leukaemia (CLL)
This form occurs in about 30% of patients
Its onset is very insidious
In 70% of patients, the diagnosis of CLL is made incidentally
The clinical features include
Anemia, neutropenia & thrombocytopenia
Disturbance of both humoral and cellular immunity (decreased antibodies & cell
mediated immunity)
Sometimes, the autoimmune phenomenon may develop
Patient may present with
Loss of energy
Tiredness
Shortness of breath
Infections at time of diagnosis but often occur later
Hepatosplenomegaly
Painless lymphadenopathy(enlarged lymph nodes)
Differential Diagnosis, Investigations and Treatment of Leukaemia
Differential Diagnosis
• Lymphomas
• Secondary malignancies from the breast, stomach, or lungs
Investigation
• The investigations for leukemia may be done and interpreted correctly by experts in the
capable hospitals and therefore referral of patients suspected of having leukemia is
necessary.
• The investigations that may be done include:
Blood count reveals the following;
Low Hemoglobin (HB)
Raised or low white blood cell counts (WBC)
Low Platelets
Blood the film will show blast cells or lymphocytes
Bone marrow aspirate (biopsy) will show infiltration of immature white blood cells
Treatment
 Treatment of leukemia cannot be performed in the primary health care facilities
(dispensary and health centers) therefore patients must be referred to hospitals for proper
treatment.
However, pre-referral treatment should be offered to ensure that the patient reaches the
hospital safely
IV fluids when there is a fluid deficit
Antibiotics when there is an infection
Counseling and psychological support to the patient as well as relatives
Described below are treatment options that can be achieved in capable hospitals.
Acute Leukaemia
Specific therapy aims at destroying leukemic clone cells without destroying the residual
normal stem cells.
The main treatment option in the treatment of acute leukemia is chemotherapy
Drugs that may be used include
Vincristine
Prednisolone
Daunorubicin
Etoposide
Cytarabine
Methotrexate.
There are three phases namely
Induction
Consolidation
Maintenance
Another treatment option is allogeneic bone marrow transplantation
Chronic Leukaemia
Depends upon the stage of the disease, the treatment of chronic leukemia may range
from nontreatment to chemotherapy and chemotherapy combined with radiotherapy
Other supportive therapy includes correction of anemia, bleeding tendency and control
of infections.                                                                                                      
REFERENCES;
•      Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed.  Oxford: McGraw Hill
•      Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.
Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.
•      Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold
•      Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford
•      Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.
•      Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF
•      Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby
•      Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.