Clinical Assessment and Risk Stratification

Acute leukaemia has a variable presentation. Usually, patients present acutely unwell to the emergency department due to symptoms or complications of the disease⁴. Occasionally, leukaemia is identified after investigations into isolated cytopaenias found incidentally in an asymptomatic patient.

Symptoms are caused by problems in the development of blood cells:

1. Symptoms of anaemia fatigue, malaise, shortness of breath, dizziness, syncope
2. Symptoms of thrombocytopaenia easy bruising, petechiae, mucosal bleeding
3. Symptoms of dysfunctional or absent white blood cells fever, infections and sepsis. Many patients have had recurrent or unusually severe infections in the build up to the diagnosis.
4. Symptoms related to a very high white blood cell count⁹
   
   Leukostasis is a hyperviscosity syndrome caused by high numbers of circulating blasts. This can result in headache, stroke, visual disturbances and respiratory failure⁹.
   
   Tumour lysis syndrome results from the rapid turnover of malignant cells. The hallmark features are renal failure, hyperkalaemia, hyperphosphataemia, hypocalcaemia and hyperuricaemia.

Patients may also report symptoms due to leukaemic cells infiltrating body tissues:

1. CNS symptoms (more likely in ALL than AML) headache, aseptic meningitis, cranial nerve palsy
2. Skin disease leukaemia cutis¹⁰
3. Gingival hypertrophy
4. Bone and joint pain more common in paediatrics and includes cases without cytopaenias^11-12
5. Mediastinal invasion superior vena cava obstruction
6. Scrotal invasion testicular swelling

Learning bite: Acute leukaemia can present in a myriad of ways. Have a low threshold to investigate further.