Monitoring day 6 ( 19 December 2017 )

SS Patients no fever, no cough, no shortness, no vomiting, appetite is

good, defecation and micturation within normal limit.
OO Composmentis , GCS 15 (E 4 M 6 V 5 )
Blood Pressure: 10 0 /60 mmHg
Heart rate: 90 times / minute, regular, sufficient contents
The rate of breath: 20 times / minute, regular, sufficient depth
Body temperature: 36, 7 o C
Pain scale based VAS : 0
BB: 17 kg
Status generalist:
- No pale
- There was palpable the left submandibular gland 1 piece
0,5x0,5cm, cervical gland dekstra 1 piece size 0,5x0,5 cm, chewy
consistency, flat surface, no tenderness, color and temperature
equal to approximately palpability.
- Bronkovesikuler breath sounds, no ronkhi and wheezing
- The liver palpable 2 cm below the right lobe of the arch of the
costa and 1 cm below the left lobe proccesusxyphoideus, chewy
consistency, flat surfaces, sharp edges, no tenderness. Lien
palpable schuffner I, chewy consistency
- No spontaneous bleeding manifestations
Examination support :
Hb 11.5 g / dl, HCT 33.1 %, MCV 76.4 fl, MCH 2 6 , 6 pg, MCHC 3 4 ,
7 g / dL, leukocytes 1 4 00 / mm 3 , ANC 16 0 / μ L , ALC 1200 / μ L,
erythrocyte 4 . 33 0000 / mm 3 , trombosit 4 6 .000 / mm 3 , neutrophils
10 , 7 %, lymphocytes 85 , 7 %, monocyte 3.6 %, eosinophil 0.0 %
and basophils 0 , 0%.
AA - Acute lymphoblastic leukemia-L1 Standard Risk
- Severe Neutropenia
 - Malnutrition
PP - IVFD dextrose 5% 2 0 drops / minute
- Premedication before chemotherapy: ondansetron 3 mg /
intravenous
- ALL chemotherapy protocol conformance L1 Standard Risk :
vincristine 0.9 mg / intraven a, daunorubicin 20mg / IV
- Prednisone 25 mg 2 - 2 - 1 tablet / oral
- Family menu, the main menu 3 times and 2 times snacks (fruits or
crackers). Calorie needs 2070 kcal, a protein with 15% from the
total calories / day = 77 grams, fat 30% of total calories = 69
grams .
- Monitoring manifestations of spontaneous bleeding.
- Monitoring on signs of infection
- Monitoring vital signs.

Monitoring day 7 ( 20 December 2017 )

SS no fever, no cough, no shortness, no vomiting, appetite is good,
regular toileting, BAK smoothly.
OO Komposmentis , GCS 15 (E 4 M 6 V 5 )
Blood Pressure: 90 /60 mmHg
Heart rate: 88 times / minute, regular, sufficient contents
The rate of breath: 24 times / minute, regular, sufficient depth
The body temperature: 36.5 o C
Pain scale based VAS : 0
BB: 17 kg
Status generalist:
- No pale
- There was palpable the left submandibular gland 1 piece
0,5x0,5cm, cervical gland dekstra 1 piece size 0,5x0,5 cm,
chewy consistency, flat surface, no tenderness, color and
 temperature equal to approximately palpability.
- Bronkovesikuler breath sounds, no ronkhi and wheezing
- The liver palpable 2 cm below the right lobe of arcuscosta ,
chewy consistency, flat surfaces, sharp edges, no tenderness.
Lien palpable Schuffner I, chewy consistency
- No spontaneous bleeding manifestations
Examination support: -
AA 1. Acute lymphoblastic leukemia-L1 High Risk
2. Severe Neutropenia
3. Malnutrition
PP - IVFD dextrose 5% 2 0 drops / minute
- Prednisone 25 mg 2 - 2 - 1 tablet / oral
- Family menu, the main menu 3 times and 2 times snacks (fruits
or crackers). Calorie needs 2070 kcal, a protein with 15% from
the total calories / day = 77 gr ams, fat 30% of total calories = 69
grams,
- Monitoring manifestations of spontaneous bleeding.
- Monitoring on signs of infection
- Monitoring vital signs.

VIII.PROGNOSIS
Quo ad vitam:bonam
Quo ad sanationam :dubia
Qua ad functionam: dubia
IX.CASE ANALYSIS
Leukemia is a malignant disease of blood cells derived from bone marrow,
characterized by the proliferation of leukocyte cells that are not controlled. Malignant
cells will perform displacement causing bone marrow failure, and also infiltrate other
tissue.1
Acute leukemia is 30-40% of all malignancies in childhood. Acute leukemia in
children achieve> 90% of all leukemia in children, and consists of two types: acute
lymphoblastic leukemia (ALL)> 80% and acute myeloblastic leukemia (LMA) 10%. The
peak incidence leukemia acute at the age of 2-5 years .1
The exact cause of leukemia is still unknown. Risk factors of leukemia are
chromosomal abnormality, chemicals, radiation and viral infections . The risk of
leukemia increased when obtained environmental factors such as exposure to
pesticides, insecticides, tobacco, petroleum products and nuclear radiation. Studies in
1,2,3

Canada stated that exposure to pesticides and insecticides during pregnancy and
childhood have a positive correlation with the occurrence of childhood leukemia.3( Level
I, recommendation B )
Mechanisms underlying leukemia, among other irregularities proto-oncogene
expression, chromosomal translocation that causes the gene fusion kinase and change
transcription factor, and there is hyperploidy involving more than 50 chromosomes.
These genetic changes contribute to leukemic transformation of stem cells and
progenitor cells to alter cellular function. They changed the regulatory process in a way
to maintain or increase the ability of unlimited self innovation, and damage control of
normal proliferation of cells, block against differentiation and promoting resistance to
apoptosis.4.5
The clinical features are due to the following matters:
1. Bone marrow failure: anemia (pallor, lethargy, and dyspnea); neutropenia (fever,
malaise, infection of the mouth, throat, skin, respiratory, perianal, or other
infections, and thrombocytopenia (spontaneous bruising, purpura, bleeding
gums)
2. Infiltration of organs: bone pain, lymphadenopathy, splenomegaly, hepatomegaly
and meningeal syndrome (headache, nausea, and vomiting, blurred vision, and
diplopia). Fundus examination may show papilledema and sometimes bleeding.
Other manifestations are swelling of the testicles or signs of compression of the
mediastinum. Leukemia potentially involving other organs in the body such as the
skin, kidneys, lungs, pleura, perikardium, eye, ovaries, and gastrointestinal tract.
3, 5

Clinical symptoms and a complete blood can be used for diagnosis of

leukemia. But be sure to do the examination of bone marrow aspirate, and chest
radiography, cerebrospinal fluid, and several other investigations such as cytochemistry,
immunology, cytogenetics, and biology, molecular. CBC obtained anemia, abnormal
leukocyte count number, and thrombocytopenia. On examination of peripheral blood
smears obtained cells blast . Based on factors prognostic then the patient can be
classified in a group of normal risk and high risk. factors prognostic high risk include:
early total leukocyte more> 50,000 / mm 3
, age <18 months or> 10 years, fenotip
immunological types of B cells, T cells, a type of male sex, the number of blast cells in
total after 1 week of treatment with dexamethasone plus 1000 / mm 3 , no mediastinal
mass, and found leukemia central nervous system (CNS) . 1
This case was diagnosed as leukemia lymphoblastic acute-L1 (LLA-L1) based
on history, physical examination and laboratory support, that is: patient present with
pale, history often fever , joint pains . On physical examination obtained
lymphadenopathy, hepatomegaly, splenomegaly, and spontaneous bleeding form of p
eteki. Results of laboratory tests on the 2 0 November 2017 showed the presence of
anemia, leiukositosis , thrombocytopenia .The results of the examination of peripheral
blood evaluation found suspicious pleomorphic cells lymphoblastt with suspected LLA
impression. The results of the examination of bone marrow aspirate was found
monotonous limfoblast cells with regular shape, core is not clear, the core ratio
cytoplasm high with LLA-L1 impression. Examination immunophenotypingshows gating
on the area blast appeared positive with: CD 34, CD 19, HLA-DR, CD 10, CD 20 ,
impression B lineage .
In this case the results obtained imunophenotypingshow gating the blast area
looks positive with: CD 34, CD 19, HLA-DR, CD 10, CD 20 , impression B lineage .
Malignant clonal of patients with ALL allegedly originated from stem cell as B
lymphocytes or T lymphocytes with impaired development . Although most patients
express the antigen B lineage (85%), but approximately 15% of patients express the
antigen T lineage such as CD1, CD 2, CD 3, CD 4, CD 5, CD 7, or CD 8. 6

Patients are children aged 6 years and 11 months with a diagnosis of LLA-L1.
At the time of diagnosis, not obtained the criteria that lead to high risk, such as age <1
year and> 10 years, leukocytes> 50,000 / mm3, the mediastinal mass, leukemia central
nervous system, the type of T-cell leukemia or mixed leukemia (bilineage leukemia) , so
these patients is given chemotherapy protocol LLA Indonesia 2006 standard risk.5
Therapy of childhood leukemia include curative and supportive therapy. Curative
treatment such as chemotherapy that aims to cure leukemia. Supportive therapy
includes treatment of other diseases that accompany leukemia, giving adequate
nutrition, approach of psychosocial aspects and treatment of complications from
leukemia either itself or due to chemotherapy. These patient is given chemotherapy
according Indonesian LLA protocol standard risk .1
This patient was in induction phase of the protocol chemoterapy LLA Indonesia
2006 Standard Risk . According to the protocol, the induction phase lasts for 6 weeks.
Sitostatica which used the induction phase is methotrexate, vincristin, L-Asparginase, d
aunorubicin , and dexametasone . The combination of these sitostatica aims to achieve
complete remission, that is blast cells <5% in the examination of bone marrow aspirate.
Sitostatica effective for malignancy due to disrupt production and the DNA of cancer
cells, but sitostatica will also disrupt fast-growing cells such as hair, nails,
gastrointestinal tract and blood cells. 7
Sitostatica have therapeutic effects and side effects are specific to each type of
drug. Vincristine has the effect of inhibition of mitosis and cause side effects such as
leukopenia, thrombocytopenia, neurotoxicity, alopecia, hypotension, and stomatitis. L-
Asparginase have the effect of L-Aspargin split and cause side effects such as allergy,
coagulopathy disorders, impaired liver function, and neurotoxic. Daunorubicin have