We determined the incidence and complications of
disseminated intravascular coagulation (
DIC) at presentation and during
remission induction of previously untreated adults with
acute lymphoblastic leukemia (ALL) or de novo
Philadelphia chromosome-positive ALL (PCALL) seen at Memorial Hospital between January 1, 1978 and December 31, 1989.
DIC was diagnosed in the presence of (1) low
fibrinogen (less than or equal to 160 mg/dL), (2) prolonged prothrombin time (PT) and falling
fibrinogen, or (3) prolonged PT and positive
fibrin split products (FSP). L-
Asparaginase was not used during
remission induction. Among adequately screened patients with ALL,
DIC was detected in 7 of 58 (12%) before initiation of
chemotherapy and in 35 of 45 (78%) during
remission induction.
DIC was not simply the result of
infection because clinical and laboratory signs of
infection were absent in 16 patients, whereas only 2 of the 22 febrile patients with
DIC had positive cultures. Among the 38 patients with
DIC at presentation or during
remission induction, serious complications were seen in 13 in temporal association with
DIC (pulmonary
embolus in one,
sagittal sinus thrombosis in three, and serious
hemorrhage in nine) and were major factors in the deaths of three patients. Among the 10 patients with thorough screening but no evidence of
DIC there was only one
hemorrhage during the same time interval. In patients with PCALL,
DIC was detected in 9% at presentation and in 80% during
remission induction. We conclude that
DIC is rare at presentation but common during
remission induction of adult ALL and PCALL and may be associated with significant thrombotic and hemorrhagic complications. We suggest daily screening for
DIC during the first 14 days of
remission induction. The treatment of
DIC in ALL and PCALL should be a subject of future clinical studies.