Severe Methotrexate Toxicity Following a Capizzi Cycle in an Obese Adolescent With Acute Lymphoblastic Leukemia and Hepatic Steatosis.

Methotrexate is a major component of pediatric leukemia treatment. While toxicities are common after high-dose methotrexate, escalating dose methotrexate (Capizzi methotrexate) is typically well-tolerated. We report an adolescent Hispanic female with pre-B acute lymphoblastic leukemia, preexisting obesity and hepatic steatosis who developed severe multiorgan failure following an escalating dose of methotrexate with delayed methotrexate excretion of 11 days. We identified one similar report in an obese adult; however, this case is the first to our knowledge involving a pediatric patient. With the rising incidence of obesity and associated comorbidities among children and adolescents with leukemia, attention to potential risks for this population is warranted.

Aspergillosis and pulmonary tuberculosis co-infection in a 9-year-old with B-cell acute lymphoblastic leukemia.

This case report highlights the infrequent occurrence of coinfection involving invasive aspergillosis and Mycobacterium tuberculosis (MTB) in pediatric patients. We present the case of a 9-year-old Thai girl diagnosed with B-cell acute lymphoblastic leukemia, who experienced prolonged febrile neutropenia lasting 1 month during chemotherapy. Chest computed tomography (CT) revealed lung nodules with an air crescent sign, while CT angiography of the brain detected an infected ruptured brain aneurysm, which exhibited septate hyphae with acute angle branching, consistent with invasive aspergillosis. Despite voriconazole treatment, the patient's high-grade fever and dyspnea persisted. Further investigations revealed a lung abscess and wedge resection confirmed AFB 1+ and positive MTB detection via polymerase chain reaction, leading to the initiation of combined treatment for pulmonary tuberculosis and invasive aspergillosis. Considering drug-drug interactions was an essential aspect of the management. This case report highlights challenges of coinfection between invasive aspergillosis and MTB.

Chronic graft-versus-host disease in children and adolescents with thalassemia after hematopoietic stem cell transplantation.

Data on chronic graft-versus-host disease (cGVHD) in patients with thalassemia after hematopoietic stem cell transplantation (HSCT) have not been specifically explored. The present study aimed to determine the incidence and clinical manifestations of cGVHD in children and adolescents with thalassemia who underwent HSCT and to compare healthcare utilization and medical cost between patients with and without cGVHD. We retrospectively analyzed the presentations, treatments, and outcomes of historical cGVHD (Seattle criteria), post-transplant admissions and direct medical cost for HSCT patients (n = 66). We used the 2014 NIH consensus criteria to reclassify the diagnosis of cGVHD (NIH cGVHD). Among 28 historical cGVHD patients, 13 (46.4%) fulfilled the NIH criteria. Reasons why the NIH criteria were unmet were reclassification as late acute GVHD and presence of distinctive signs without confirmatory tests. At 2 years after HSCT, the cumulative incidence of NIH cGVHD was 21.67% (95% CI, 12.31-32.74%). Lung cGVHD was associated with inferior survival with a hazard ratio of 13.6 (95% CI, 1.42-131.48). Patients with historical cGVHD had significantly increased frequency of inpatient admissions and medical cost. In conclusion, cGVHD was common in children with thalassemia receiving HSCT. Patients with cGVHD required prolonged immunosuppressive treatment and incurred high medical expenses.