Case ReportAcute LymphocyticLeukemiaMimickingRenalFailure

AtiyaKhan,M.D.Lucius F. Sinks, M.D.MichaelSilhaug,M.D.LorraineChampion,M.D.

A 14-year-old white female presented inSeptember 1977 with a two week historyof anorexia, vomiting, lethargy, andweight loss. Physical examination revealed a listless adolescent in no acutedistress. Her blood pressure was 120/70mmHg. She had no adenopathy or organomegaly. There was no family historyof gout. Laboratory studies revealedblood urea nitrogen of 150/di and serumcreatinine of 4l/dl, with a creatinineclearance of 5.2 ml/rninute per 1.73/rn2.The serum uric acid was 41 mg/dl,hemoglobin 11 gm/dl, and white bloodcell count 7,500/mm3 with a normal differential. Platelet count was 237,000/mm3. The serum calcium was 8.4 mg/dl,serum phosphorus 11 mg/dl, and potassium 6.4 mg/dl. A renal sonogram andarteriogram demonstrated bilaterally enlarged kidneys, and a renal biopsy showedsome areas of interstitial nephrosis. No

Dr. Khan is a Fellow in the Division ofPediatric and Adolescent Oncology, Georgetown Hospital, Washington, D.C.Dr. Sinks is Chief, Department of Pediatricand Adolescent Oncology, Georgetown Hospital, Washington, D.C.

Dr. Silhaug is a Fellow in the Departmentof Pediatrics and Nephrology, GeorgetownHospital, Washington, D.C.

Dr. Champion is with the Division of Pediatric Oncology, Children's Hospital, Washington, D.C.

evidence of infiltration was reported. Herbone marrow aspirate was normal.

She was treated with hydration, allopurinol, alkalization, peritoneal dialysis and finally hemodialysis. Over a sixweek period, her serum uric acid returned to normal and her serum BUNand creatinine fell to 29 mg/dl and 1.6mg/dl, respectively. She was maintainedon allopurinol.

Two weeks after discharge, the patient was readmitted with a serum uricacid concentration of 42 mg/dl. TheBUN was 56 mg/dl, and the serum creatinine 6.2 mg/dl. Hemoglobin was 9.5mg/dl, white blood cell count 5,900 witha normal differential and platelet count143,000/mm3. Serum concentrationsof adenineophosphoribosyl transferasehypoaxanthineguanine-phosphoribosyltransferase were normal. A gallium scanwas normal. A report bone marrow aspiration showed five percent lymphoblasts but was otherwise normal. She wastreated with hydration, alkalination andallopurinol; her uric acid fell to 8 mg/dl,BUN to 51 mg and creatinine to 1.5mg/dl.

Two months later, she was readmitted with a third episode of hyperuricemia. Splenomegaly and cervical adenopathy were noticed for the first time. Herhemoglobin, white blood cell count andplatelet count were normal. The bonemarrow aspirate revealed 55 percent

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lymphoblasts and a diagnosis of ALLwas made. She was induced into remission with prednisone and vincristine.Despite careful hydration and an increase in the allopurinal, she developedan exacerbation of the uric acid nephropathy. Her BUN rose to 170 mg/dl, hercreatinine to 4.4 mg/dl. The calcium fellto 5.9 mg/dl, with a serum phosphoruslevel of 11 mg/dl, and she developed hy

pocalcemic tetany. These metabolic abnormalities responded to conservativemeasures and hemodialysis was not instituted. Her serum BUN, uric acid, andcreatinine returned to normal after onemonth of chemotherapy.

She has now completed inductionand sanctuary therapy (21 mo), remainsin remission, and her renal status is completely normal.

THE SCIENTIST/MAGUS

itisnotsurprisingthattraditionalmythologylinksthefigureofthescientistwiththatoftheMagus. The Magi were thepriestsof theancientZoroastrianreligionofPersia,and theword “¿�magic―isderivedfrom theirname. The myth of thescientistMagus appears in its most explicit form in the legend of Faust, the learned man whosells his soul to the Devil in return for occult knowledge and magical power. Theremarkable thing about the Faust legend is that everybody to some extent still believesin it. When you say that some piece of technology is a Faustian bargain, everybodyknows what you mean. Somewhere below the level of rational argument, the mythisalive.

From: Reflections: Disturbing the Universe-i, Freeman Dyson, The New Yorker, August 6,i979, p 40.

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