Reader’s Question on Leukemia in Chinese girls

In dealing with the medical aspects of international adoption, the usual outcome is almost always a happy ending. Yes, there are those cases where there is an underlying medical condition, developmental delay or emotional trauma. Fortunately, most of these cases can be treated with medications, therapy or surgery. When I treat an internationally adopted child, I obtain the greatest professional satisfaction because I know that I made a difference is a child’s life. I know that if this child was not adopted by their family , their medical problems would have gone undetected, because no one cared to look for them and more than likely their illness would have gone untreated.

Every day in my clinical practice I deal with all types of children with variable types of medical conditions.
On my website , I answer many questions placed by worried adoptive families. This question that I am answering today I write about with a heavy heart. As physicians we are trained to deal with all aspects of tragedy, but rarely would a physician encounter a case such as the one I will be describing. The topic today is about a Chinese girl that was fortunate enough to be adopted, and was in excellent medical health for years post adoption. She had very rarely been to the doctor’s office other than for routine well care visits. It was not until over two after coming home did this child become acutely ill and succumb to her death secondary to acute leukemia.

Many people are now wondering if Leukemia is a problem specific to children adopted from China? Is there a test that could be performed for leukemia prior to adopting, and most importantly, does hereditary a play a key factor in the diagnosis?

The short answer to this question is No! I feel that this was just an unfortunate case.

Leukemia is the most common form of childhood cancer and it generally can affect almost any child anywhere. There are some suspected risk factors which I will mention but all in all no one can predict which child will and which child will not get leukemia.

In this article, I will do a brief over view of leukemia in order to help educate those worried families out there.

Usually, the leukemia is a cancer of the white blood cells, but leukemia can involve other blood cell types as well. Leukemia starts in the bone marrow and then spreads to the blood. From there it can go to the lymph nodes, spleen, liver, the brain and spinal cord, testicles or other organs. Leukemia is described as rapidly growing (acute) or slow growing (chronic). Almost all childhood leukemia is acute.

The fast growing leukemia is divided into 2 types:
– acute lymphocytic leukemia (ALL, also called acute lymphoblastic leukemia)
– acute myelogenous leukemia (AML, also called acute myeloid leukemia, acute myelocytic leukemia, or acute non-lymphocytic leukemia (ANLL))

Leukemia is the most common cancer in children and adolescents. It accounts for almost one third of all cancers in children under age 15. ALL is most common in early childhood, peaking between 2 and 3 years of age. AML is most common during the first 2 years of life and is less common among older children. ALL is slightly more common among white children than among African-American and Asian-American children, and is more common in boys than in girls.

AML occurs equally among boys and girls of all races.
What Are the Risk Factors for Leukemia? A risk factor is defined as anything that can increases a person’s chance of getting a disease such as cancer.

Genetic Risk Factors
Certain genetic or inherited diseases cause children to be born with an abnormal or deficient immune system. In addition to developing serious infections due to their reduced immune defenses, these children also have an increased risk of developing leukemia.

Although these immune deficiency diseases can be passed on to children, adult leukemia survivors who do not have these inherited diseases do not pass an increased risk of leukemia on to their children.

There are also several other inherited disorders that increase a child’s risk of developing leukemia:

Children with Down’s syndrome (trisomy 21) have an increased risk of developing leukemia. Children with Down’s syndrome are 15 times more likely to develop either ALL or AML than are other children.

Klinefelter’s syndrome is a genetic condition in which males have an extra “x” chromosome. This causes infertility, prevents normal development of male features (such as body hair, deep voice, etc.), and is also associated with an increased risk of developing leukemia. Several other genetic disorders (neurofibromatosis, ataxia telangectasia, Wiscott-Aldrich Syndrome, and Fanconi’s anemia) also carry an increased risk of developing leukemia,

Environmental Risk Factors
Environmental risk factors, such as radiation and certain chemicals, in our surroundings may increase the likelihood of developing leukemia.

Radiation exposure: Radiation injury is a major environmental risk factor in developing childhood leukemia. Japanese survivors of the atomic bomb had an increased risk of developing AML, usually within 6-8 years after exposure. Similar risks occurred after exposure to nuclear reactor accidents. Exposure of the fetus to significant radiation within the first months of development may also carry an increased risk of developing ALL.

Certain chemicals: Exposure to chemicals such as benzene may cause AML in adults and, rarely, in children. ALL has not been linked to any cancer-causing chemicals.

Other factors that have been studied for a possible association with ALL include exposure to insecticides; mother’s age at birth; mother’s use of alcohol, cigarettes, diethylstilbestrol (DES), or contraceptives; father’s occupational exposure to chemicals and solvents; and chemical contamination of ground water. Now one could say that some of these things may be found in an orphan child’s environment, but it would not be specific to just China, it could be from anywhere in the world. Regardless, none of these factors has been linked conclusively to leukemia.

Can Leukemia be prevented?
Children with a known increased risk of developing leukemia (because of Down’s syndrome, for example) should receive careful, periodic medical checkups and at that time routine complete blood counts or CBC. The frequency of leukemia in children with these syndromes, although greater than in the general population, is still very rare.

Signs and Symptoms of Childhood Leukemia
Most of the signs and symptoms that children with leukemia develop result from a lack of normal blood cells caused by crowding out of normal blood cell-producing bone marrow by the leukemia cells. It has been my experience that children do not just come to the office with a Diagnosis of leukemia. They tend to have multiple visits with strange complaints. Their illness or symptoms never completely resolve or they just get worse. The diagnosis is usually suspected after a physician does a complete blood count and it is discovered that the blood lines are abnormal.

Sometimes children present with repeated infections that do not respond to antibiotics. They can have a high fever, and become very sick. Also, some children present with vague symptoms of leg pain that is initially diagnosed as growing pain. Leukemia is a cancer of white blood cells, children with leukemia may have extraordinarily high white blood cell counts, but these affected leukemic cells do not protect against infection the way normal white blood cells do. Thus the classic case is a child with prolonged fevers that do not respond to conventional therapy even after many days to weeks.

A child with leukemia may bruise easily or have increased bleeding from small cuts and nosebleeds. There may be pinhead-sized red spots on the skin that represent bleeding from tiny bl
ood vessels. This results from poor production of blood platelets, which are important for plugging holes in damaged blood vessels.

Some children present with recurrent bone pain. Many times they may be diagnosed initially with growing pain. The diagnosis again is suspected after an abnormal CBC is performed. The pain is caused by an accumulation of the leukemia cells underneath the covering of the surface of the bone. Some children will also have a lack of appetite.

Unfortunately, a poor appetite is run of the mill in Pediatrics. Leukemia often causes enlargement of the liver and spleen. Enlargement of these organs would be noticed as a fullness, or even swelling, of the belly. The lower ribs usually cover these organs but when they are enlarged, the doctor can feel them.

Leukemia can also spread to lymph nodes. The child, a parent, or a health care professional may notice swollen nodes that are close to the surface of the body (lymph nodes on the sides of the neck, in the groin, underarm areas, above the collarbone, etc.). Swelling of lymph nodes inside the chest or abdomen may also occur. These are sometimes detected only by imaging tests, such as CT or MRI scans.

Headache, seizures, vomiting: Leukemia cells can spread outside the bone marrow. This is called “extramedullary spread.” It may involve the brain and spinal cord, the testicles, ovaries, kidneys, lungs, heart, intestines, or other organs. Headache, poor school performance, weakness, seizures, vomiting, difficulty in maintaining balance, and blurred vision can be symptoms of CNS leukemia.

Rashes, fatigue, and weakness: AML can cause some unique symptoms. Leukemia cells may spread to the gums, causing swelling, pain, and bleeding. Spread to the skin can cause small darkly colored spots that can resemble common rashes. One unusual but very mysterious consequence of AML is extreme tiredness, weakness, and slurring of speech, which occurs when very high numbers of leukemic cells make the blood too “thick” and interfere with circulation through small blood vessels of the brain.

As you can see, leukemia is a very difficult diagnosis to predict. Suspicion for this illness should be made when a child presents with what appears to be vague or mysterious signs and symptoms that do not resolve after the routine time frame. The suspicion is generally made after a good history and physical examination is performed followed by a complete blood cell count. The definitive diagnosis is made by a bone marrow aspiration.

Written By George Rogu M.D. CPE Founder of and

For Domestic & International Adoption Medical Record Review