CASE DESCRIPTION
An otherwise well, developmentally normal, 3-year-4-month-old female
with a history of AT, presented with fever, abdominal pain, anorexia,
weakness, weight loss and nocturnal sweating. She underwent a bone
marrow biopsy and aspirate and was diagnosed with B-ALL. Her past
medical history was significant for severe alopecia areata involving
80% of her scalp which began at 11 months of age. This was treated with
intermittent topical fluocononide 0.05% ointment, intermittent topical
clobetasol 0.05% ointment, 2% minoxidil solution and topical
diphenylcyclopropenone (DPCP) 0.01%. The family elected to stop topical
therapy after 19 months due to a limited clinical response. The alopecia
progressed to involve the entire scalp with sparing of the eyebrows,
eyelashes and body hair.
The patient’s B-ALL was treated with chemotherapy as per the Children’s
Oncology Group (COG) protocol AALL 0932 (average risk arm) as a
registered study patient. She achieved full morphologic and minimal
residual disease (MRD) remission at the end of induction, which included
intrathecal cytarabine and methotrexate, intravenous vincristine and
PEG-asparaginase and oral dexamethasone. Thereafter, she received the
consolidation, interim maintenance I and II, and delayed intensification
cycles of chemotherapy. Theses cycles included oral 6-mercaptopurine,
intrathecal and intravenous methotrexate, intravenous vincristine, oral
6-thioguanine, oral dexamethasone, intravenous cytarabine, intravenous
cyclophosphamide, intravenous doxorubicin, and intravenous
PEG-asparaginase. She was subsequently randomized to Arm-C of the
protocol, which included daily oral 6-mercaptopurine, weekly oral
methotrexate, and intrathecal methotrexate, intravenous vincristine and
a 5-day oral dexamethasone pulse given every 12 weeks.
Chemotherapy was well tolerated and there were no unexpected toxicities.
Treatment was completed in July 2013.
Prior to initiation of chemotherapy, the patient had hair loss involving
the entire scalp and had not undergone treatment for her AT for 6
months. Two months after the start of maintenance chemotherapy, her hair
began to re-grow with complete remission and no recurrence of the AT
despite chemotherapy completion for more than 6 years. Aside from
keratosis pilaris on her arms and one episode of molluscum contagiosum,
she has not had any new dermatologic concerns and remains in remission
from AT and B-ALL.