Moroccan Journal Of Public Health Vol. 2, N° 1 (2021), 45-49 ISSN: 2658-8099
Management of acute myeloid leukemia in Covid 19 era
Fatima Ezzahra RIDA1*
, Asmaa HARRACH1*
, Hasnaa JABRI²*, Meryem QACHOUH1 *
, Mohamed RACHID1*
, Abdellah MADANI1*
, Mouna LAMCHAHAB1*
1: Department of clinical hematology and pediatric oncology, Ibn Rochd University hospital center, Casablanca 20000, Morocco 2: Department of Pneumology, Ibn Rochd University hospital center, Casablanca 20000, Morocco
*: Faculty of Medicine - Hassan 2 Casablanca University, Morocco
Corresponding Author E-mail: Ridafzaa@gmail.com
Received : April 2021 Accepted : June 2021 Online : July 2021
Acute myeloid leukemia, Covid 19,
The covid 19 pandemic has not spared patients with hematological malignancies. The hematologist community faces unprecedented challenge since the first identification of this new virus. In this study, we aim to describe characteristics and outcome of patients with acute myeloid leukemia (AML) diagnosed with covid 19 infection at different states of the disease. A total of 16 COVID-19-infected patients with AML were included; 4 (25%) patients were male. The average age was 37 years. 7 patients had a favorable, 7 intermediate and 2 high risk AML. We noted no case of hemorrhagic syndrome and only 1 patient developed a deep vein thrombosis. Treatment of AML was postponed in 11 patients. 4 patients who contracted the SARS-COV2 infection undergoing intensive myelosuppressive chemotherapy. 2 patients had severe events and only 1 patient died. Patients with AML may show favorable outcomes of COVID 19 infection even while treated with intensive chemotherapy.
Coronavirus disease has changed life overnight and impact the management of patients suffering from cancer in general and particularly patients with AML, we need more studies to better understand different aspects of this microscopic particle and its impact on the management of these patients.
On January 30, 2020, the World Health Organization
declared the CoViD-19 pandemic as a public health emergency of international concern. Over 130 million cases have been confirmed worldwide with over 2 million deaths. In Morocco, the first case was identified in March 2
and to date we count more than 500,000 cases.
Several studies suggest that cancer patients have a higher risk of serious events compared to non-cancer patients (39% vs 8%) [Gavillet et al. 2020].
Acute myeloid leukemia (AML) is a malignant disorder of the bone marrow which is characterized by the clonal expansion and differentiation arrest of myeloid progenitor cells. [Shallis RM et al. 2019]. Patients with acute myeloid leukemia may develop a Covid 19 infection concomitantly with the diagnosis or during the course of treatment, which compromises the therapeutic management in these patients.
We report a series of 16 patients followed for acute myeloid leukemia diagnosed with covid-19 managed at our department, and we aim to describe clinical characteristics and treatment outcome of these patients.
2. Material and methods
We carried out a retrospective study at the department of hematology of Ibn Rochd University Hospital of Casablanca over a 12-month period from March 30, 2020 to March 30, 2021, involving patients with acute myeloid leukemia having a concomitant infection with COVID 19.
The diagnosis of SARS infection -CoV-2 was based on the detection of the virus by real-time polymerase chain reaction (SARS-CoV-2 E-gene RT-PCR) in respiratory tract specimens. Epidemiological, clinical data, laboratory findings and treatment outcome were retrieved from the patient’s medical records.
We enrolled 16 patients. The average age was 37 years [20-68], the sex ratio M / F was 0.33. No one has associated comorbidities apart from AML. 2 patients
developed SARS COV 2 infection at diagnosis, 8 at complete remission 3 at induction failure and 2 were under palliative treatment. The cytogenetic study of blast cells allowed patients to be classified into 3 prognostic groups according to European Leukemia Net (ELN), 7 patients had a favorable, 7 intermediate and 2 high risk AML.
Testing for SARs-COV2-RNA by RT-PCR was indicated in symptomatic patients in 44% and for screening in 56%.
Patients in which chest computed tomography (CT) was performed n=7 showed bilateral ground glass opacities in 5 cases and was normal in 2 cases. All the patients had received treatment according to the national protocol with oral hydroxychloroquine (200 mg *3/day for 10 days) in association with azithromycin 500 mg on day 1 then 250 mg per day from day 2 to day 7, vitamin c and zinc. 2 patients were admitted to the intensive care unit with the development of COVID pneumonia; one patient required noninvasive ventilation for 4 days with good progress and the 2nd patient had developed acute respiratory distress syndrome (ARDS) and required mechanical ventilation.
Deep vein thrombosis was observed in a single patient 20 days after infection. The control PCR on D14 was carried out in 2 patients and confirm the absence of SARS COV 2 infection. Serological follow-up was not done. No patient presented with hemorrhagic syndrome during this period.
Regarding treatment of AML during the COVID19 infection period, the treatment was delayed in 11 patients, 4 patients were undergoing intensive chemotherapy with grade 4 neutropenia and developed infection indoors despite isolation and hygienic measures. In our series, only one patient died due to a severe course of complicated COVID 19 septic shock.
Table I. clinical and evolutionary characteristics of patients
Patients number n=16
Prognostic groups according to ELN:
Favorable Intermediate High
7 7 2
43,7 43,7 12,5 Disease state:
At diagnosis Complete remission Failure
2 8 3 2 1
12,5 50 18,75 12,5 6,37 Symptoms at onset:
Fever Cough Myalgia
Respiratory distress Contact with infected Asymptomatic
4 3 2 2 1 7
25 19 12 12 6 44 Treatment site:
Medical service ICU
6 2 8
38 12 50 Complications:
ARDS Sepsis Thrombosis
2 2 1
12 12 6 Evolution:
Figure 1. Aspect of ground glass opacities in the two pulmonary fields producing a crazy paving appearance in one of our patients
4. Discussion: The The treatment of acute myeloid leukemia with intensive chemotherapy induces severe and prolonged neutropenia exposing the patient to a high risk of infection of bacterial, fungal or viral origin. [Ferrara et al. 2020]. The exact incidence of COVID-19 in patients with cancer in general, and in patients with leukemias in particular, is unclear. [Zeidan et al. 2020]. The prognosis of covid-19 infection in patients with cancer and hematological malignancies is difficult to determine, and remains controversial. Initial reports from China suggested that patients with cancer are at a 3·5 times higher risk of severe COVID-19 compared with the general population [Liang et al. 2020]. Other data, based on post- transplantation cohorts, argue that, unlike common viral agents, coronaviruses do not cause more severe disease [L. D’Antiga, 2020]. In Morocco, analysis of the causes of death linked to COVID-19 concluded that the most significant factors were; age ≥ 65 years, the presence of cancer and mal sexe. [Youbi 2020]. In our study;
25% were males. 2 patients required hospitalization in the intensive care unit, and death occurred in only one patient. In these struggling times, the hematology staff face an enormous challenge, from diagnosis to treatment to various complications of AML. Regarding diagnosis, the similarity of clinical signs of SARS COV infection and leukemia may delay the diagnosis of covid19 in these patients. As 50–75
% of patients with acute leukemia are febrile at diagnosis, they are at high risk of missed or delayed diagnosis. [ Burke et al. 1976]. In addition
to diagnostic delay, most patients may suffer from postponed chemotherapy, which may negatively affect prognosis, particularly in young (< 60 years-old) patients with favorable- or intermediate-risk disease. [Gavillet et al. 2020].
The American Society of Hematology has recommended postponing induction 1 in patients with symptoms of COVID 19 until clinical signs improve. Low-intensity therapies, such as a hypomethylating agent with VENETOCLAX can be safely administered on an outpatient basis.
[DiNardo et al. 2019]. Since the diagnosis of the first case in our unit, all our patients are screened before admission. This systematic screening for COVID 19 by RTQ-PCR detected infection in seven asymptomatic patients. For this group of patients, AML treatment was delayed for up to 14 days. This preventive action made it possible to avoid the initiation of immunosuppressive treatment in patients with silent active infection.
For patients in remission awaiting consolidation treatment, our strategy was also based on the reduction of aracytine dose from 3g / m2 to 1.5g / m2 with the reduction in the number of cycles from 4 to 3. In the literature based on findings from the MRC 15 trial, lowering the dose of cytarabine from 3 gm / m2 to 1.5 gm / m2 could minimize the duration of myelosuppression without sacrificing long-term outcomes. [Burnett et al. 2013] More- over, reducing the number of cycles from four to three may also lower the risk of infection. [Mayer et al. 1994]. Use of myeloid growth factors further reduces the duration of neutropenia, the risk of infection, and the need for hospitalization.
In our study, we found no evidence that acute myeloid leukemia significantly influenced the course of the disease;
even immunocompromised patients on cancer treatment may have a favorable outcome. Optimized management of COVID-19 is essential in order to identify and treat patients with more severe disease progression.
Understanding and managing this pandemic remains a challenge, whether the prevention against its spread, the appropriate treatment or vaccination.
Conflicts of Interest
The authors declare that they have no competing interest
The authors thank the pneumology department, the radiology department, the reanimation department and the laboratory of Ibn Rochd university hospital of Casablanca for their contribution to the diagnosis and treatment of patients.
Burnett AK, Russell NH, Hills RK, Hunter AE, Kjeldsen L, Yin J, Gibson BE, Wheatley K, Milligan D.
Optimization of chemotherapy for younger patients with acute myeloid leukemia: results of the medical research council AML15 trial. J Clin Oncol. 2013 Sep 20;31(27):3360-8. doi: 10.1200/JCO.2012.47.4874.
Epub 2013 Aug 12. PMID: 23940227.
DiNardo CD, Pratz K, Pullarkat V, Jonas BA, Arellano M, Becker PS, Frankfurt O, Konopleva M, Wei AH, Kantarjian HM, Xu T, Hong WJ, Chyla B, Potluri J, Pollyea DA, Letai A. Venetoclax combined with decitabine or azacitidine in treatment-naive, elderly patients with acute myeloid leukemia. Blood. 2019 Jan 3;133(1):7-17. doi: 10.1182/blood-2018-08-868752.
Epub 2018 Oct 25. PMID: 30361262; PMCID:
Ferrara, F., Zappasodi, P., Roncoroni, E., Borlenghi, E.,
& Rossi, G. (2020). Impact of Covid-19 on the treatment of acute myeloid leukemia. Leukemia, 34(8), 2254-2256.
Gavillet, M., Klappert, J. C., Spertini, O., & Blum, S.
(2020). Acute leukemia in the time of COVID- 19. Leukemia research, 92, 106353.
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Li C, Ai Q, Lu W, Liang H, Li S, He J. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.
Lancet Oncol. 2020 Mar;21(3):335-337. doi:
10.1016/S1470-2045(20)30096-6. Epub 2020 Feb 14.
PMID: 32066541; PMCID: PMC7159000.
Lorenzo. Coronaviruses and immunosuppressed patients: the facts during the third epidemic. Liver Transplantation, 2020, vol. 26, no 6, p. 832-834
Mayer RJ, Davis RB, Schiffer CA, Berg DT, Powell BL, Schulman P, Omura GA, Moore JO, McIntyre OR, Frei E 3rd. Intensive postremission chemotherapy in adults with acute myeloid leukemia. Cancer and Leukemia Group B. N Engl J Med. 1994 Oct
10.1056/NEJM199410063311402. PMID: 8078551.
P.J. Burke, H.G. Braine, H.K. Rathbun, A.H. Owens Jr.
(1976) The clinical significance and management of fever in acute myelocytic leukemia, Johns Hopkins Med. J. 1–12
Shallis RM, Wang R, Davidoff A, Ma X, Zeidan AM.
Epidemiology of acute myeloid leukemia: Recent progress and enduring challenges. Blood Rev. 2019 Jul;
o i . 2020 and mie ovid- , pid miologie et perspectives de surveillance et de riposte au Maroc.
22/09/2020. Direction de l'Epidémiologie et de Lutte contre les Maladies .
Zeidan AM, Boddu PC, Patnaik MM, Bewersdorf JP, Stahl M, Rampal RK,et al . (2020) Special considerations in the management of adult patients with acute leukaemias and myeloid neoplasms in the COVID-19 era: recommendations from a panel of international experts. Lancet Haematol. Aug;7(8): e601- e612.