What Are Some Pediatric Oncological Emergencies?

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Patient Presentation
An 8-year-old female came to the hospital ward with fever up to 101.3 F and neutropenia. She was in her maintenance phase of chemotherapy for acute lymphoblastic leukemia and had received her last chemotherapy 3 weeks previously. Despite using granulocyte stimulating medications, she had had several previous hospitalizations for fever and neutropenia and had responded to antibiotics and monitoring without additional complications. She did endorse some mild abdominal pain but no specific nausea, emesis or diarrhea. The review of systems was negative for respiratory problems, other pain, rash, neurological problems or musculoskeletal problems. She was tired, but parents said this was usually true around this time of her chemotherapy cycle. She had some mild mucositis and was being treated with her oral regimen. She was drinking fairly well and urinating well.

The pertinent physical exam showed a slightly pale and tired patient with normal vital signs including a normal blood pressure. Her weight was 24.1 kg (just below 50%) and down 500 grams from her last clinic visit. HEENT showed alopecia. Mild buccal and tongue ulcerations without obvious thrush. She had no other mucositis noted or obvious lymphadenopathy. Her abdominal exam revealed some mild periumbilical tenderness without guarding. There was no pain in McBurney’s point and no costovertebral angle or suprapubic tenderness. She had no obvious masses and no hepatosplenomegaly. Her bladder was not distended. The rest of her examination was normal.

The laboratory evaluation showed a hemoglobin of 10.3 g mg/dL, total neutrophil count of 485, platelets were 130 x 1000/mm2. Other laboratories were normal include electrolytes, liver function tests, amylase and lipase, uric acid and lactate dehydrogenase.

The diagnosis of fever and neutropenia was made. She was started on antibiotics. The senior resident reminded the interns to monitor her closely especially for abdominal pain. “I know that this looks like a usual fever and neutropenia admission, but you never know that. It could always be something else, so watch her belly tonight. If you aren’t sure, just call me. I’d rather hear about it than not,” she reminded them. The patient’s clinical course showed that her abdominal pain resolved and she was released on day 5 after 24 hours fever free and her hematological counts were increasing.

Discussion
Pediatric cancers in the US number about 12,000 per year. After injury, it is the second leading cause of death in children and adolescents. Cancer presentations vary widely, but often begin with non-specific symptoms that continue or progress depending on the location and tumor type. Patients can present with oncological emergencies especially if there are mechanical obstruction such as superior vena cava syndrome or cerebral herniation. More commonly are infections due to immunosuppression. Cancer treatment also causes its own myriad of problems that clinicians need to be aware of to diagnosis and treat, but again they can have insidious or non-specific presentations. Patients often present with a commonly anticipated problem such as fever and neutropenia or abdominal pain, but it may be a sign of something more emergent. Patients not acting right initially, or not responding to treatment as expected, may have another problem.

Learning Point
Pediatric oncological emergencies include:

  • Cardiovascular/Pulmonary
    • Pericardial effusion or tamponade
    • Hemoptysis
    • Infection
    • Pulmonary embolism
  • Gastrointestinal
    • Bowel obstruction or perforation
    • Infection – appendicitis, tyhilitis or neutropenic colitis
    • Intussception
    • Pancreatitis
  • Hematologic
    • Anemia
    • Bleeding
    • Disseminated intravascular coagulation
    • Hyperleukocytosis
    • Leukopenia
    • Thrombocytopenia
    • Thrombosis
    • Transfusion reactions
  • Infection
    • Fever and neutropenia
    • Infection – bacterial, fungus, viral, parasitic
    • Septic shock
  • Metabolic
    • Tumor lysis syndrome
    • Calcium, hypo- or hyper-
    • Phosphate, hyper-
    • Potassium, hyper-
    • Sodium, hypo-
    • Urea, hyper-
  • Mechanical
    • Airway obstruction
    • Cerebral herniation
    • Spinal cord compression
    • Superior vena cava obstruction
    • Other locations that obstruct outflow
  • Neurologic
    • Cerebrovascular accidents
    • Seizures
    • Syndrome of inappropriate antidiuretic hormone
  • Other
    • Medication side effects
    • Medication interactions
    • Organ failure
    • Tumor rupture
  • Other problems, not necessarily are emergencies but can be
    • Dehydration
    • Graft vs host disease
    • Immunosuppression
    • Iron overload
    • Mucositis
    • Pain

Questions for Further Discussion
1. What are the most common pediatric cancers? A review can be found here
2. How do pediatric cancers present?
3. Steroids are used for many problems. What is the problem with using steroids if there is an undiagnosed malignancy?
4. What are PDQs from the National Cancer Institute and how can they be helpful? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Cancer in Children and Cancer – Living with Cancer.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Prusakowski MK, Cannone D. Pediatric Oncologic Emergencies. Hematol Oncol Clin North Am. 2017;31(6):959-980. doi:10.1016/j.hoc.2017.08.003

Stephanos K, Picard L. Pediatric Oncologic Emergencies. Emerg Med Clin North Am. 2018;36(3):527-535. doi:10.1016/j.emc.2018.04.007

Handa A, Nozaki T, Makidono A, et al. Pediatric oncologic emergencies: Clinical and imaging review for pediatricians. Pediatr Int Off J Jpn Pediatr Soc. 2019;61(2):122-139. doi:10.1111/ped.13755

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published