Symptoms

1. Onset usually abrupt, simulating acute septic condition; occasionally there may be a prodromal period of malaise; or abnormal bleeding after tooth extraction, etc. may be the first symptom.

2. Usually fever, chills, prostration, sore throat, headache and joint pains.

3. Bleeding, especially from the following:

(a) Gums

(b) Oral mucous membrane

(c) Nose

(d) Vagina

(e) Rectum

4. Symptoms secondary to anemia (weakness, dyspnea, palpitation, etc.).

Signs

1. Marked pallor.

2. Evidence of hemorrhagic phenomena.

(a) Bleeding as just listed under symptoms

(b) Petechiae, ecchymoses in skin

(c) Retinal hemorrhages

3. Swelling, discoloration, and secondary infection (especially with the monocytic variety) of the gums, oral and pharyngeal mucosa, and tonsils.

4. Spleen slightly to moderately enlarged.

5. Liver moderately enlarged.

6. Lymph nodes often enlarged in a generalized fashion but not prominent.

7. Tenderness over the sternum.

8. A variety of neurologic syndromes are possible secondary to hemorrhage and/or leukemic infiltration.

9. Hemorrhage and/or secondary infection may be prominent in the late stages of the disease and may be the terminal events.

Chronic Leukemia. Symptoms

1. May be none for months or even years.

2. Onset usually insidious:

(a) Fatigue

(b) Lassitude

3. Symptoms secondary to anemia may be noted:

(a) Weakness

(b) Palpitation

(c) Dyspnea

(d) Fatigue

(e) Dizziness

(f) Accentuation of co-existing angina pectoris

4. Symptoms secondary to hypermetabolism may be noted:

(a) Weakness

(b) Weight loss

(c) Perspiration

(d) Tachycardia

(e) Increased body warmth

5. Symptoms secondary to organ and lymph node enlargement may be noted:

(a) Especially the spleen in the myelocytic type (dragging sensation, abdominal distention).

(b) Especially the nodes in the lymphocytic type.

(c) The liver in myelocytic and lymphocytic types.

(d) Mechanical pressure in certain specific areas (e.g., on the bronchi, bowel, urinary tract, or central nervous system) may give rise to corresponding respiratory, digestive, urinary, or neurologic symptoms and signs. Any one of these may dominate the clinical picture.

6. After months or even years, during which the disease was classified as "chronic," a transformation to the "acute" state may take place.

7. Hemorrhagic manifestations usually reflect the terminal state or an acute exacerbation of the disease.

8. Symptoms secondary to involvement of the gastrointestinal tract (especially the stomach and ileum), particularly in the lymphocytic variety.

9. In the later phases hemorrhage and/or infection may be prominent and contribute to eventual demise. These may be the dominant features of the disease and overshadow all other manifestations in some patients.

Steps In The Diagnosis And Initial Management Of The Leukemia Suspect. Examination Of Peripheral Blood By Usual Techniques. White Blood Count And Differential

1. In acute leukemia:

(a) The total count is usually 15,000 to 30,000 per cubic millimeter. It is rarely over 100,000 and may even be normal or below normal.

(b) The differential count usually shows primitive unclassifiable stem cells predominating. Occasionally tentative assignment to a myelocytic, lymphocytic, or monocytic category is possible on the ordinary smear. Some advocate supravital and other stains to assist in this differentiation. Usually, however, acute leukemia resists such a specific classification.

2. In chronic myelocytic leukemia:

(a) Total counts are the highest found in the leukemias. The usual range is 100,000 to 500,000 per cubic millimeter but may be lower or even go as high as 1,000,000.

(b) In the early stages the differential may show 20 to 60% mature myelocytes with an occasional myeloblast.

(c) As times goes on the myelocytes and myeloblasts increase in number, and the smear may later show 70% or more myeloblasts.

(d) Rarely a basophilic or eosinophilic variety of leukemia can be diagnosed.

3. In chronic lymphocytic leukemia:

(a) The total count is in the intermediate range, e.g., 50,000 to 250,000.

(b) The differential often shows 60 to 90% small adult lymphocytes.

Hemoglobin and hematocrit determination, red blood cell count, and platelet count

1. In acute leukemia, anemia and thrombocytopenia are usually profound and early manifestations.

2. In both myelocytic and lymphocytic leukemia, anemia and thrombocytopenia are more commonly late or terminal manifestations, although they may sometimes be present to a mild, subclinical degree even in the early stages.