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After completing this case study, the reader should be able to:

  • Interpret the laboratory values that signify the response of acute lymphocytic leukemia (ALL) to chemotherapy.

  • Describe the ancillary medications and supportive care measures that are necessary when administering chemotherapy to patients with ALL.

  • Recommend the appropriate medications to treat neutropenic fever.

  • Identify the backbone of therapy for treatment of adult ALL.

  • State why CNS prophylaxis is routinely done in adult patients with ALL.


Chief Complaint

Episodic sweating, dizziness, and progressively worsening weakness and shortness of breath on exertion × 1 month.


Ian Hamilton is a 58-year-old man with a past medical history of diabetes, hyperlipidemia, and hypertension who presents with episodic diaphoresis, dizziness, and progressively worsening weakness and dyspnea on exertion for 1 month. He has lost 40 lb in the past 9 months; he recently has been trying to eat more but is still losing 2 lb per week. Flow cytometry done 3 days ago at an outside hospi­tal showed blastic B cells consistent with pre–B-cell lymphoblastic leukemia. The patient was found to have normocytic anemia (Hgb 9.9 g/dL). He also had a CT of the chest/abdomen/pelvis completed at the outside hospital due to weight loss and occasional abdominal pain and sensation that his stomach is “churning,” although no report was sent with his records. He denies diarrhea but admits to once having an episode of dry heaving. A CXR was unremarkable. The patient was previously taking Janumet for type 2 DM, but since this workup began, he stopped it and has had blood sugars in the 100–130s.


DM type 2




Father had MI at age 60 and leukemia at age 78 and expired shortly thereafter. Mother is alive with heart disease, skin cancer, an unknown GI malignancy, and a recent diagnosis of lymphoma. He has five brothers and two sisters. One brother died at age 48 from Hodgkin lymphoma, diagnosed at age 18. Another brother has multiple sclerosis. The other three brothers and both sisters are healthy.


Denies tobacco, EtOH, and illicit drugs. Drives a waste management truck, has three children, and lives with his wife.






Constitutional: Positive for sweats, fatigue, anorexia, and weight loss

HEENT: Negative

Respiratory: Positive for dyspnea

CV: Negative

GI: ...

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