Thrombosis and Acute Myeloid Leukemia In Morocco: Management, Difficulties and Adapted Guidelines

Thromboembolism is a well-known fatal complication of malignancies. Acute lymphoid leukaemia and non-Hodgkin lymphomas are the most common haematological malignancies associated to thrombosis. The management of thrombosis involve anticoagulant treatment which is difficult to administrate in thrombocytopenic patients especially in conditions where supportive care by platelet transfusion is not well developed, and the cost of low molecular weight heparin is high comparing to population monthly income.

Our aim is to define the incidence of thrombosis in AML patients, to relate difficulties of anticoagulant management and to develop adapted guidelines for the use of anticoagulation in developing countries.

We conducted a retrospective study on 1000 patients with newly diagnosed AML admitted to our institution from January 2003 to June 2013. Diagnosis of AML was essentially based on French–American–British (FAB) guidelines. Moreover, diagnosis of acute promyelocytic leukemia (APL) was confirmed by karyotype. Deep venous thrombosis (DVT) was confirmed by Doppler ultrasonography and cerebral thrombosis (CT) was confirmed by angio cerebral MRI. The thrombosis scoring was according to Khorana and well scores. Patients started chemotherapy induction treatment as soon as diagnosed and anticoagulation treatment was initiated when the patient was stable. Platelet transfusions were given when platelet count became less than 10 G/L, or 20G/ L in the case of fever or bleeding. Were included in the study all patients with inaugural thrombosis at diagnosis. And were excluded all secondary thrombosis (catheter related thrombosis. etc.)

Only five cases of inaugural thrombosis were collected in our series. The incidence of thrombosis is 0.5/ 100 cases /year. Thrombosis is well misdiagnosed in our conditions. The mean age was 40 years (range 28-48 years). Sex ratio showed male predominance. The mean platelet count (Plt) at diagnosis was at 36.6 G/l (range 4- 98 G/l). Hyperleucocytosis was seen in two cases with a mean of white blood count (WBC) of 21.6 G/l (range 1- 82 G/l). One patient was diagnosed as APL. Wells score was less than three in all patients. Khorana score classed all patients in low or intermediate risk. Four patients had DVT and one patient complained from CT. The time from thrombosis to anticoagulant treatment ranged from 1 day to 3 days. Two patients were treated by LMWH and died (one from pulmonary embolism). The three others were treated by unfractionated heparin (UNH) and achieved complete remission (CR). (Table).

UNH is the best adapted treatment of thrombosis in developing countries AML patients. Supportive care by platelet transfusion twice a day stays the best way to well manage AML and anticoagulant complications by keeping platelet count more than 50G/l.

No relevant conflicts of interest to declare.