key: cord-0991140-6l71ytx3
authors: Marcia, Marta; Vania, Barbara; Pruccoli, Giulia; Vallero, Stefano G.; Barisone, Elena; Scolfaro, Carlo; Fagioli, Franca
title: Acute lymphoblastic leukemia onset in a 3‐year‐old child with COVID‐19
date: 2020-07-24
journal: Pediatr Blood Cancer
DOI: 10.1002/pbc.28423
sha: 2134891300f534ab7e748cf9d88560db8b4be67a
doc_id: 991140
cord_uid: 6l71ytx3

nan

To the Editor:

An epidemic cluster of pneumonia cases caused by the novel coronavirus, SARS-CoV-2, first broke out in Wuhan City, China in December 2019. 1 This infection, named COVID-19, then spread rapidly throughout continents and was declared pandemic on March 11, 2020. Currently, there are only anecdotal reports of COVID-19 in immunosuppressed children [2] [3] [4] or in pediatric patients with cancer, and so far there is only one Chinese case report 5 We hospitalized a 3-year-old boy with fever, epistaxis, and weight loss. His mother, although asymptomatic, had already tested positive in a SARS-CoV-2 nasopharyngeal swab. She was tested again on arrival at hospital and resulted negative. At presentation, the patient had mild fever, bruises, hepatosplenomegaly, and multiple lymphadenopathy. He was neither coughing nor in respiratory distress.

Blood tests showed hyperleukocytosis, anemia, and thrombocytopenia (white blood cells [WBC] 85.23 × 10 9 /L, hemoglobin 5.7 g/dL and platelets 19 × 10 9 /L); other results included normal C-reactive protein, prothrombin time, activated partial thromboplastin time, and uric acid. A peripheral blood smear showed 80% lymphoid blasts. The chest X-ray showed a mild diffuse bronchial wall thickening and the chest computed tomography scan was normal. His nasopharyngeal swab tested positive for SARS-CoV-2, so he was isolated in a COVID ward and started receiving antibiotic treatment and intravenous hydration.

From the first day of his hospitalization, the patient started COVID-19 treatment with lopinavir/ritonavir (140/35 mg BID) associated with hydroxychloroquine (HCQ; 5 mg/kg BID for the first day and then 2.5 mg/kg BID).

The bone marrow smear showed 90% lymphoid blasts FAB L2 on morphology; immunophenotype was compatible with "common" ALL (CD123+/CLL1−). The lumbar puncture was negative for blasts.

On day 4, a pruritic confluent maculopapular skin rash ( Figure S1 In fact, such WBC reduction is improbably related only to IV hydration and blood transfusions.

Besides its recognized use in rheumatologic and infectious diseases, HCQ has been known to have an antineoplastic effect. 7 Many ongoing clinical trials are focusing on combining treatment of chloroquine-HCQ with standard chemotherapies, demonstrating prolonged survival rates in certain types of cancer. 8 However, chloroquine therapy does not show significant benefits in vivo, possibly due to its inability to reach effective drug concentrations. 7 The use of lopinavir/ritonavir associated with HCQ in COVID-19 pediatric patients was based on local guidelines supported by the current literature. [9] [10] [11] Additional evidence supports the potential use of human immunodeficiency virus protease inhibitors (HIV-PI; eg, lopinavir) as antineoplastic drugs. 12 On consulting these reported scientific data, we were confident in starting the concurrent COVID-19 therapy, taking into consideration the possible impact on the patient's leukemic course. Our report shows that treatment of childhood acute leukemia in the setting of a concomitant SARS-CoV-2 infection may be successful. The timing of chemotherapy and the antiviral treatment must be carefully weighed on a case-by-case basis. In our patient, a prompt initiation of anti-COVID-19 drugs and a rapid viral clearance allowed us to start leukemia treatment with just a slight delay and did not prevent a satisfactory tumor response.

Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement

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Coronaviruses and immunosuppressed patients: the facts during the third epidemic

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Autophagy is dispensable for Kmt2a/Mll-Mllt3/Af9 AML maintenance and anti-leukemic effect of chloroquine

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SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section at the end of the article