2. Dilemma between disease and infection control
Outcome of paediatric AML is generally fair with an overall survival around 70% and a relapse rate of 30 to 40% after primary treatment. Infective complications post-induction is common but NTM infection is possible but rare, thus it had been postulated that our child reported might have an underlying congenital immune defect along the macrophage/interleukin-12/IFN-γ pathway apart from acquired immunodeficiency due to haemic malignancy and cytotoxic therapy (16). Premature termination of chemotherapy without consolidation may increase relapse risk but further administration of high dose chemotherapy might result in uncontrolled disseminated NTM infection which could lead to limb amputation or even death. In view of high relapse risk without consolidation chemotherapy, the option of allogeneic hematopoietic stem cell transplantation (HSCT) had been explored and discussed. Potential benefits of HSCT include graft-versus-leukemia effect which prevent disease relapse and reconstitution of healthy cellular immunity against mycobacterial infection but at the cost of ultra-high infection and mortality risk even with non-myeloablative reduced intensity conditioning or mini-transplant. After multidisciplinary discussion among paediatric oncologists, microbiologists, orthopedic surgeons together with parents and child, it was finally decided to control infection first and consider HSCT in case of disease relapse.