Clinical Findings. Leukemia
A. Symptoms and Signs: Most patients with acute leukemia present with an acute illness and have been ill only for days or weeks. Bleeding (usually due to thrombocytopenia) is usually in the skin and mucosal surfaces, manifested as gingival bleeding, epistaxis, or menorrhagia. Less commonly, widespread severe bleeding is seen in patients with disseminated intravascular coagulation (seen in acute promyelocytic leukemia and monocytic leukemia). Infection is due to neutropenia, with the risk of infection becoming high as the neutrophil count falls below 500/mL. Patients with neutrophil counts less than 100/mL almost invariably become infected within several days. The most common pathogens are gram-negative bacteria (E coli, Klebsiella, Pseudomonas) or fungi (Candida, Aspergillus). Common presentations include cellulitis, pneumonia, and perirectal infections. Septicemia in severely neutropenic patients can cause death within a few hours if treatment with appropriate antibiotics is delayed.
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Patients may also seek medical attention because of gum hypertrophy and bone and joint pain. The most dramatic presentation is hyperleukocytosis, in which a markedly elevated circulating blast count (usually > 200,000/mL) leads to impaired circulation, presenting as headache, confusion, and dyspnea. Such patients require emergent leukapheresis and chemotherapy.
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On examination, patients are usually pale and have purpura, petechiae, and various signs of infection. Stomatitis and gum hypertrophy may be seen in patients with monocytic leukemia. There is variable enlargement of the liver, spleen, and lymph nodes. Bone tenderness, particularly in the sternum and tibia, may be present.