APTI ijopp - Indian Journal of Pharmacy Practice

Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009APTIijoppL-ASPARAGINASE INDUCED CENTRAL VENOUS THROMBOSIS IN ACUTELYMPHOBLASTIC LEUKEMIA1 2 1 1 1Lavanya S , Vijayan K , Abhay Dharamsi , Rajasekaran A Vijayakumar A1,3 .1. Drug and Poison information Center, Department of Pharmacy Practice,KMCH College of Pharmacy,Kalapatti road, Kovai Estate, Coimbatore - 6410482. Consultant, Department of Neurology, Kovai Medical Center and Hospital, Coimbatore- 641014Address for Correspondence: vijayspharm@gmail.comBackgroundTo report a case of central venous thrombosis following treatment of acute lymphoblastic leukemia withL-asparaginase. A 13-year-old master presented with an acute lymphoblastic leukemia associated with threeepisodes of focal onset convulsions with secondary generalization, headache and altered sensorium. He was2 2initially treated with 5000 u/m of L-asparaginase followed by 10,000 u/m every third day for 4 weeks. After aweek’s course of L-Asparaginase, the patient experienced central venous thrombosis. MRI showed thrombosis ofthe sagittal, transverse and straight sinuses on the right side with partial recanalisation, suggesting a drug inducedneurotoxic reaction. According to the Naranjo probability scale, the central venous thrombosis was probablycaused by L-Asparaginase. L-Asparaginase-induced central venous thrombosis is rarely reported shortly afterbeginning L-asparaginase therapy in patientswith acute lymphoblastic leukemia. However, bleeding or thrombosisoccurring as a direct result of changes in coagulation factors has not been frequently reported. The purpose is toevaluate the current knowledge of central venous thrombosis in association with ALL in children. Health careprofessionals should be aware of this potential adverse reaction and monitor the patients regularly duringL-asparaginase therapy.Key Words: L-asparaginase, Central Venous Thrombosis, Acute Lymphoblastic Leukemia.INTRODUCTIONCASE REPORTAcute lymphoblastic leukemia (ALL) is more frequent in A 13-year-old boy was presented to Kovai Medicalchildren than in adults; indeed, two thirds of all cases Center and Hospital, India in January 2005, with1occur at pediatric age . The risk of thrombosis is complaints of three episodes of focal onset convulsionsincreased in ALL patients, and its occurrence maywith secondary generalization. History revealed headcomplicate the treatment course with a negativeturning to left follow by generalized tonic-clonic2prognostic impact . L-asparaginase hydrolyses L-convulsions. Hemoglobin was 10.6 g/dl, leukocytes 1700asparagine which is a non essential aminoacid. L-cells/cumm, and the platelet count 1, 07,700 cells/cumm.asparaginase is used particularly in acute lymphoblasticThe differential count revealed 16% lymphocytes, 81%leukemia (ALL) and in other hematologicalmalignancies such as acute myeloblastic leukemianeutrophils, and 3% monocytes. The patient's bone(3,4)(AML) and lymphoma . Therapy has been associated marrow aspiration showed 90% blasts (L1 typewith various forms of toxicity, including according to French-American-British (FAB)hypersensitivity, coagulation abnormalities and classification) with Periodic acid Schiff reaction (PAS),(5,6)others . L-asparaginase shows this effect by decreasing sudan Black and myeloperoxidase stains negative. The(7,8)the synthesis of coagulation proteins . In literature, patient was on prednisolone, vincristine, daunorubicin, l-thrombosis is emphasized more than hemorrhagic asparaginase, methotrexate and cytosine. Computedcomplications due to L-asparaginase. This report Tomography (computerized type of x-ray that gives verydescribes a case who developed central venous detailed images of internal organs such as the brain) scanthrombosis confirmed by Magnetic Resonance Imagingof the brain was normal but during the next 48 hours, he(MRI) during L-asparaginase therapy.developed weakness of the left upper limb.The prothrombin time was 29 seconds, the partialIndian Journal of Pharmacy PracticeReceived on 12/01/2009 Modified on 11/02/2009thromboplastin time 48 seconds fibrinogen, protein C,Accepted on 24/02/2009 © APTI All rights reservedprotein S, antithrombin III levels were normal. Serum81