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Acute lymphoblastic leukaemia (ALL) in children
ALL is the commonest cancer in children, peaking at age 2–5; it shows itself through bone-marrow failure (pallor, bleeding, fever) and organ infiltration (bone pain, enlarged liver, spleen and lymph nodes), and cure rates today are very high.
Why it matters in the exam
The exam describes a child with prolonged fever, pallor, petechiae and leg pain that wakes him at night or makes him limp. The candidate must recognise that involvement of more than one cell line on the count, together with organ enlargement, requires a blood smear and a bone-marrow examination. Follow-up questions deal with prognostic factors, tumour lysis syndrome and an anterior mediastinal mass in T-ALL.
An important trap is "JIA" — a child with joint pain who receives steroids before a diagnosis; steroids can mask leukaemia and spoil the diagnosis and the risk classification. In tumour lysis, treatment is hydration and allopurinol or rasburicase — but rasburicase is contraindicated in G6PD deficiency, which is common in some communities in Israel. Fever with neutropenia in a child on chemotherapy is an emergency: broad-spectrum antibiotics within an hour.
Children with Down syndrome are at increased risk of ALL and AML, and are more sensitive to treatment toxicity. Treatment lasts about two to three years and includes preventive treatment of the central nervous system.
Key points
- The commonest cancer in children; peak at age 2–5.
- Marrow failure and organ infiltration: pallor, bleeding, fever, bone pain, organ enlargement.
- Standard risk: age 1–9 and a white count below 50,000.
- Tumour lysis: hydration and allopurinol or rasburicase (not in G6PD).
- Fever with neutropenia: antibiotics within an hour.
Summary table
| Issue | Details | Exam note |
|---|---|---|
| Presentation | Pallor, fever, petechiae, bone pain and limp, enlarged liver and spleen, lymph nodes | The white count can be low, normal or high |
| Diagnosis | Blood smear and bone-marrow examination with flow cytometry and genetics; lumbar puncture for CNS involvement | Do not give steroids before the diagnosis |
| Standard risk (NCI) | Age 1–9 years and a white count below 50,000 | A good early response (negative MRD) improves the prognosis |
| High risk | Age under one year or 10 or more, white count of 50,000 or more, T-ALL, CNS involvement, unfavourable genetics (KMT2A, hypodiploidy) | BCR-ABL1 — a tyrosine kinase inhibitor is added |
| Tumour lysis | High potassium, phosphate and uric acid, low calcium; kidney failure | Hydration, allopurinol or rasburicase (not in G6PD deficiency) |
| T-ALL | Adolescents, anterior mediastinal mass | Risk of airway obstruction under anaesthesia; superior vena cava syndrome |
A free exam question
בן 3 ( שנים, חולה לוקמיה ALL), כשבוע לאחר טיפול כ י מותרפי באמצעות ליין מרכזי, לא ידועה רגישות יתר לתרופות. מתייצג במיון עם ח ו ם 38.7˚c . סימנים חיוניים תקינים, מצב כללי טוב. לא ידועה נשאות לחיידקים עמידים, ללא טיפול אנטיביוטי מונע. בבדיקה גופנית – מדדים חיוניים תקינים. ללא ממצא מכוון לחום, צילום חזה תקין. במעבדה- ABSOLUTE NEUTROPHIL COUNT -50 cell/mm3 מהו שילוב הטיפול האמפירי המומלץ ביותר ? (the question as examined, in Hebrew)
- א. IV VANCOMYCIN+ IV PIPERACYLIN-TAZOBACTAM
- ב. IV AMPICILLIN+ IV AMIKACIN
- ג. IV PIPERACYLIN-TAZOBACTAM+/- AMIKACIN
- ד. IV VANCOMYCIN+ IV MEROPENEM
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
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Sources
- Nelson Textbook of Pediatrics, 22nd edition (2024) — The Acute Leukemias
- NCI/Children's Oncology Group risk classification for childhood acute lymphoblastic leukemia, current edition — Age, white-cell count and genetic risk groups
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.