leukemia reaction
Introduction
Introduction to leukemia-like reactions The leukemia-like reaction is a kind of cell growth or left shift reaction caused by a certain factor stimulating the hematopoietic tissue of the body, which is like leukemia. Its classification is more, among which neutrophil type is the most common. This disease is most common in some serious infections of bacteria and viruses. It is also often found in malignant tumors, acute hemolysis and certain drug reactions. The disease is more common in children and adolescents, and there is no difference in the incidence of men and women. The leukemia-like response is a response of normal bone marrow to certain stimuli. basic knowledge The proportion of illness: 0.0035% Susceptible people: good for children and adolescents Mode of infection: non-infectious Complications: anemia, hemolytic anemia
Cause
Causes of leukemia-like reactions
Infection (40%):
It is the most common cause. Common pathogens include bacteria, spirochetes, protozoa, viruses, etc. The leukemia-like reactions caused by infection are divided into the following categories:
1, granulocyte-type leukemia reaction: common in pneumonia, meningitis, diphtheria, tuberculosis (mainly miliary tuberculosis, invasive tuberculosis dissolution and dissemination period, extrapulmonary tuberculosis) and other serious infectious diseases.
2, lymphocytic leukemia reaction: common in pertussis, chickenpox, infectious mononucleosis, infectious lymphocytosis, tuberculosis and so on.
3, monocytic leukemia reaction: common in tuberculosis, cytomegalovirus infection, subacute bacterial endocarditis.
4, eosinophilic leukemia reaction: common in parasitic infections, such as schistosomiasis, filariasis, malaria, hydatid disease (hydatid disease).
Malignant tumors (30%):
More common in advanced patients, lung and gastrointestinal malignant tumors, especially metastasis to the liver, prone to leukemia reaction after multiple bone marrow, multiple myeloma, Hodgkin's disease, melanoma, osteosarcoma, breast cancer, chorionic epithelial cancer Leukemia-like reactions have also been reported. Tumor-like leukemia-like reactions are mostly granulocyte-like and similar to erythroleukemia. Lymphocyte types are rare, often accompanied by anemia and thrombocytopenia.
Poisoning (20%):
1. Chemical factors: such as mercury, organic phosphorus, benzene, nitrite and other poisoning.
2, drug properties: such as arsenic, antipyretic analgesics, sulfa drugs, adrenaline, glucocorticoids, lithium salts, etc., there are reports: high-dose cytarabine treatment of leukemia-like reactions caused by acute leukemia remission .
3, other: eclampsia, carbon monoxide poisoning, tetrachloroethane poisoning, uremia, ketoacidosis, food poisoning, etc.
4, acute blood loss and hemolysis
Major bleeding caused by any cause, acute intravascular hemolysis.
5, acute tissue damage
Common in traumatic tissue trauma (such as craniocerebral trauma, crush syndrome), extensive burns, in addition to pulmonary infarction, myocardial infarction, electroshock and so on.
6, other diseases
Allergic diseases (such as exfoliative dermatitis, hypersensitivity pneumonitis), hyperthermia, ionizing radiation disease, splenectomy, late pregnancy, etc.
(two) pathogenesis
Increased peripheral blood leukocytes or immature cells are abnormalities in cell production or release, which may be accompanied by defects of elimination and destruction. The specific mechanisms are inconsistent. The main viewpoints are as follows:
1. Changes in cell regulatory mechanisms
Hematopoietic cell proliferation and differentiation are regulated by a variety of cell growth factors, which play an important role in leukemia-like reactions.
When microorganisms or endotoxins enter the body and are swallowed by macrophages, the host defense system responds quickly, and macrophages and T cells are activated to produce various hematopoietic growth factors such as G-CSF, GM-CSF, and M-CSF. And release cytokines, lymphokines (such as IL-1, IL-3, TNF, etc.), lL-1, IL-3, TNF and bacterial products can stimulate the secretion of GM-CSF and G-CSF, CM -CSF, G-CSF, IL-3, etc. can stimulate the proliferation and differentiation of bone marrow hematopoietic stem cells and precursor cells, and promote the release of neutrophils from the reservoir to the marginal pool and circulation pool, so that the peripheral blood white blood cell count is significantly increased. At the same time, some immature cells such as early granules and protoplasts may appear to exhibit leukemia-like changes. When the microorganisms are encapsulated or cleared, the factors that stimulate the expression of colony stimulating factor (CSF) gene are eliminated, and the peripheral blood leukocyte count can be Back to normal.
The regulation of eosinophils is similar to that of neutrophils. Many factors such as antigen-antibody reaction, foreign proteins, parasites, etc. can cause eosinophilia, and eosinophils can be stimulated by eosinophil releasing factor. The resulting diffusible factors are derived from eosinophil colony-stimulating factor of sensitized T cells and low molecular weight polypeptides which can stimulate eosinophils to promote the proliferation and release of eosinophils. Is a sensitized T cell subset, which synthesizes cytokines (such as IL-5), stimulates the proliferation, differentiation, and release into eukaryotic cells in a short period of time, with leukemia-like changes, eosinophils The release is selective and rarely occurs in naive eosinophils.
In addition, some tumor cells can also produce colony-stimulating factors, stimulate hematopoietic cell proliferation, differentiation, release, toxins, hypoxia, immune reactions, chemical substances and other factors can damage bone marrow capillary endothelial cells to damage the medullary blood barrier, resulting in Some of the naive cells enter the blood circulation, and leukemia-like reactions occur. After splenectomy, the bone marrow may lose some of the control effect. Therefore, when some external factors stimulate the bone marrow, it is easier to release the young or young red blood cells into the peripheral blood.
2. Extramedullary hematopoiesis
Myelofibrosis, advanced cancer and chronic severe anemia can occur extramedullary hematopoietic foci in the liver and spleen, and neutrophils and nucleated red blood cells can appear in the peripheral blood.
3. Redistribution of blood cells
Infectious lymphocytosis, infectious mononucleosis, peripheral blood lymphocytes increased significantly, young lymphocytes may also appear, may be related to lymphocyte redistribution, pertussis patients with pertussis can produce a lymphocyte inhibition The factors that transfer blood to the tissue cause the lymphocytes to stay in the blood for too long and increase in number. At this time, the lymphocytes in the blood are mainly helper T cells. In addition, in some patients with infection recovery, due to the needs of tissues Neutrophils are reduced, causing neutrophils to accumulate in the peripheral blood, and a leukemia-like reaction occurs.
Prevention
Leukemia-like reaction prevention
The key to preventing this disease is to avoid the primary cause.
1. Minimize infection and avoid exposure to harmful substances and drugs.
2, to prevent carbon monoxide poisoning, food poisoning.
3, for eclampsia, uremia, acute blood loss, hemolysis, acute tissue trauma, malignant tumors in a timely and effective treatment.
4, exercise at the right time, enhance physical fitness, improve their disease resistance.
Complication
Leukemia-like complications Complications anemia hemolytic anemia
Because leukemia-like reactions are secondary to other diseases, the complications vary from primary to major. The most common complications are secondary infection, fever, liver and spleen, swollen lymph nodes, anemia, and hemolytic anemia.
Symptom
Leukemia-like reaction symptoms common symptoms lymph node swelling shock
Can be seen in all age groups, but children are more common, the incidence of male and female is no difference, the clinical manifestations are mainly the symptoms and signs of the primary disease, fever is more common, may have liver, spleen, lymphadenopathy and skin ecchymosis and other bleeding symptoms In a 76-series series, the incidence of splenomegaly was 20.0%, and in another 50-series series, the incidence of splenomegaly was 22.0%, but generally only mild swelling, because the leukemia-like reaction was secondary to other diseases, Therefore, there is no specific clinical manifestation, and the symptoms and signs vary depending on the primary disease.
Examine
Examination of leukemia-like reactions
Laboratory inspection
1. Blood picture: The average value of hemoglobin in the two larger series is 116g/L, 124g/L, the average white blood cell is 22.7×109/L, 28.0×109/L, and the average platelet count is 274×109/L. , 275 × 109 / L, leukemia-like patients with hemoglobin and platelet counts are generally normal, white blood cell count is generally (50 ~ 100) × 109 / L, in patients with tuberculosis-like leukemia response, there are reports of white blood cells up to 220 × 109 / L There are a few small naive cells in the white blood cell classification, but mainly in the near mature stage. The granulocytes are rarely >15%, there is no Auer corpuscle, and 75% of the cells are mesozoic cells and late myelocytes and alkaloids. Up to 15% of granulocytes are reported. Leukemia-like reactions are often accompanied by erythroblastemia, neutrophils often have poisonous particles, and sometimes Döhle bodies.
2, bone marrow: hematopoietic cell proliferation is active, granulocyte can have nuclear left shift, but the original granulocyte is rarely more than 20%, generally no Auer small body, but also occasionally seen in tuberculosis leukemia reaction, red and giant nucleus are generally normal, Cancerous bone marrow metastasis-like leukemia reactions can also be seen in varying numbers of cancer cells.
3. Cytochemical staining: The neutrophil alkaline phosphatase score was significantly increased.
4. Genetic examination: no Ph1 chromosome.
5. Others: Peripheral blood neutrophil alkaline phosphatase is normal or elevated, and tetrazolium blue staining is significantly increased in response to infectious leukemia.
Film degree exam
1, X-ray: tuberculosis X-rays suggest tuberculosis, lung infection chest X-ray can be prompted.
2, B-ultrasound: liver, spleen, swollen lymph nodes.
3, pathological characteristics of bone marrow: sinusoidal blood vessels are normal or slightly increased, often with false Gaucher cells, mast cells are easy to see, iron-containing granule macrophages can be significantly increased, fat cells are abnormally distributed, most of which are distributed in trabecular bone Next.
Diagnosis
Diagnosis and diagnosis of leukemia-like reaction
Diagnose based on
First, there are clear causes, such as more serious infections, poisoning, malignant tumors, major bleeding, acute hemolysis, anaphylactic shock, medication history.
Second, laboratory inspection:
1. The measured values of red blood cells and hemoglobin are basically normal, and the platelet count is normal.
2, granulocyte-type leukemia reaction: white blood cell count 50 × 10 9th / L or more, or peripheral blood and promyelocytic cells appear; mature neutrophil cytoplasm often appear toxic particles and vacuoles, In addition to the phenomenon of hyperplasia and left shift, there is no cell morphology abnormality of leukemia (such as imbalance of cell nucleus and cytoplasm, abnormal nuclear nuclei, more or more nucleoli, etc.), and mature neutrophil alkaline phosphatase score is obvious. Increase.
3, lymphocytic leukemia reaction: white blood cell count increased significantly, more than 50 × 109 / L, of which more than 40% are lymphocytes; if white blood cells < 50 × 109 / L, which atypical lymphocytes should be > 20%, and young Lymphocytes.
4, monocyte-type leukemia reaction: white blood cell count is above 30 × 10 9 / L, mononuclear cells > 30%; if white blood cells < 30 × 109 / L, young mononuclear cells should be > 5%.
5, eosinophilic leukemia-like reaction: peripheral blood in the eosinophils increased significantly, no immature cells; bone marrow like primitive cells, no Ph chromosome and eosinophil morphology abnormalities, the proportion of primitive cells in the bone marrow No increase in eosinophil morphology.
6, erythroleukemia-type leukemia reaction: peripheral blood in young red and young cells, in addition to granulocyte cell proliferation in the bone marrow, there are erythroid cell proliferation, peripheral blood leukocytes and nucleated red blood cells total > 50 × 109 / L There are immature granulocytes; if the total number of white blood cells is <50×109/L, the original granulocytes should be >2%.
7, plasma cell type leukemia reaction, the total number of white blood cells increased or not increased, peripheral plasma cells > 2%.
8, leukocyte no increase in type leukemia reaction: white blood cell count is not high, but the emergence of immature cells in the peripheral blood.
Third, after the removal of the primary disease, the blood picture changes can return to normal.
Fourth, the classification of bone marrow cells is normal or basically normal, and is not synchronized with the surrounding blood picture, and there is no leukemia cell tumor-like morphology.
LR is a complication, or an intermediate pathological process, mainly in hematological abnormalities, so clinical history and signs can not provide any diagnostic clues, blood test is the key to diagnosis, the main significance of bone marrow examination is to exclude leukemia, the original The existence of the disease, and the recovery of the primary disease after the recovery of blood is the most important diagnostic basis, especially the acute leukemia reaction, can not be distinguished from acute leukemia in a certain period of time, follow-up dynamic observation is the only identification means.
Differential diagnosis
There are many clear causes of leukemia-like reactions, but when the primary disease is more concealed, attention should be paid to the identification of leukemia.
First, the leukemia-like reaction itself does not require treatment. After the primary disease is removed, it can be quickly recovered. Therefore, the primary disease should be carefully searched for and actively treated.
1. After the cause of the leukemia-like reaction is removed, the blood image can return to normal.
2, when the leukemia-like reaction, there is generally no significant anemia and thrombocytopenia.
3. When leukemia-like reactions occur, granulocytes have severe toxic changes, and cytoplasm contains toxic particles and vacuoles.
4. In the leukemia-like reaction, the alkaline phosphatase activity and sugar of neutrophils were significantly increased, while in granulocytic leukemia, both were significantly reduced; 5 Ph1 chromosome was found in chronic myeloid leukemia cells, and leukemia-like reactions were observed. No, leukemia-like reaction - leukemoid reaction is usually caused by severe infection, some malignant tumors, drug poisoning, massive hemorrhage and hemolysis reaction, which cause abnormal reactions caused by hematopoietic tissue. Leukocytes are significantly increased (up to 50,000/1 or more), and there are naive cells. The treatment and prognosis of leukemia-like reactions are different from leukemia. Generally, medical history and cell morphology can be differentiated from leukemia, but sometimes it is difficult.
two,
1. Although the hematological changes of the white-like reaction are diverse, most cases are not difficult to diagnose; but the difference between patients with lymphadenopathy, splenomegaly, fever or hemorrhage is more difficult than leukemia, and some cases are only in autopsy. Only when the diagnosis, leukemia-like reaction and leukemia are the main identification points.
2, malignant tumors are not only prone to leukemia-like reactions, but also prone to bone marrow metastasis, and even bone marrow metastasis as the first symptom. Normal bone marrow cells are inhibited by tumor cells and become "neoplastic leukemia". At this time, it should be differentiated from leukemia-like reactions. It should be differentiated from the primary leukemia, and the primary lesion should be searched for timely and correct treatment.
