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.