Management of Philadelphia chromosome-positive acute lymphoblastic leukemia in a Jehovah's Witness in an outpatient setting: A case report

Abstract

Jehovah's Witnesses are known to decline transfusion of blood products. We present a case of an adult Jehovah's Witness with Philadelphia chromosome (pH)-positive B-cell acute lymphoblastic leukemia (B-ALL) managed successfully using less intensive chemotherapy with tyrosine kinase inhibitor without need for blood transfusion. The patient presented with anemia (hemoglobin of 95 g/L) and leukocytosis (WBC count of 208.79 × 109/L). The patient was treated with pre-phase chemotherapy using prednisone at 1 mg/kg/day for three weeks then underwent induction chemotherapy using L-asparaginase, vincristine and prednisone (LVP). Bone marrow aspirate flow cytometry revealed residual blasts of 11.94%. After reinduction chemotherapy using five cycles of cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP), two cycles of rituximab with imatinib 600 mg/day, he achieved complete remission. Lowest hemoglobin level was 70 g/L during the twelfth day of induction chemotherapy using LVP. Lowest platelet count, WBC count and absolute neutrophil count were 54 ×109/L and 0.55 × 109/L, and 148/microL respectively, which were noted during the nineteenth day of the first cycle of CHOP chemotherapy. Consolidation chemotherapy with three cycles of CHOP, two cycles of rituximab and imatinib were continued. The patient achieved a molecular response of 0.59% by QRT PCR BCR ABL after completion of chemotherapy. This case highlights a successful management using a non-myelosuppressive chemotherapeutic regimen for a Jehovah's Witness patient diagnosed with pH-positive B-ALL. Shared decision-making between the patient and the physician must be observed. Balancing the goal of cure and avoidance of blood transfusion should be done through discussions on treatment options and possible outcomes. These allow respect for patient autonomy and provision of best possible care for the patient.