Rachael Woods
Minor Case Study:
Hodgkin’s Lymphoma in the Pediatric Population
February 25th, 2014
Figure 1.1 (1)
Introduction:
B.T. is a 17-year-old Hispanic female who weighs 90.8 kg (199.8 lb) and has a height
of 154.5 cm (60.8in). Additional anthropometrics of B.T. are provided below in Table 1.1.
B.T. was admitted for generalized back pain and neutropenia secondary to Hodgkins
Lymphoma (HL). B.T. was chosen for this study because the nutritional implications for
cancer, specifically HL are of great interest; especially since proper nutrition is one factor
that can be used to prevent the occurrence of cancer altogether. This study began on
January 22nd, 2014, and ended on January 24th, 2014. The objective of this study is to
closely examine the nutritional requirements for patients, particularly pediatric patients
who are battling HL.
Table 1.1 B.T.’s Anthropometrics
Height for Age
5-10th
Weight for Age
>95th
IBW
44 kg
% IBW
206%
BMI
37.9 (Obese Class II)
BMI for Age
>95th
Social History:
B.T. is currently a junior in high school and resides at home with her mother; she
does not have any siblings. B.T. is Catholic and receives Florida Medicaid. Family
responsibilities for B.T. are those of a typical teenager: She does the dishes, takes out the
trash, and does her own laundry. B.T.’s mother is responsible for grocery shopping and
preparing meals. B.T. denied drinking alcohol and smoking cigarettes.
1
Normal Anatomy and Physiology:
HL manifests within the lymphatic system, or the immune system. HL typically
arises in one lymph node and then begins spreading to “anatomically contiguous lymphoid
tissues”(2). A normally functioning immune system fights off pathogenic organisms that
may cause harm to the body. The lymphatic system is comprised of lacteals, lymph, lymph
nodes, lymphatic vessels, tonsils, the thymus gland and the spleen (3). The lymphatic
system begins its circuit in the lymphatic capillaries and lacteals; lymphatic capillaries are
located in tissues throughout the body and lacteals are lymph vessels located around the
small intestines. Excessive fluid build-up in tissues drain into lymphatic capillaries and fats
that have been digested are absorbed from the intestines into lacteals (3).
Lymphatic capillaries merge into larger lymphatic vessels and flow unidirectionally
toward the thoracic cavity. Valves along their length prevent lymph from flowing in the
opposite direction (3). The lymphatic vessels drain into either the right lymphatic duct or
thoracic duct; the right lymphatic duct drains into the right subclavian vein and the
thoracic duct drains into the left subclavian vein (3).
Throughout the lymph’s journey from the body to the subclavian veins, it
encounters components of the lymphatic system: the lymph nodes and the spleen. Lymph
nodes are comprised of lymphatic tissues (tissues consisting of lymphocytes and
antibodies) and are located throughout the length of the lymphatic system. The purpose of
the lymph nodes is to remove pathogens and cell debris as the lymph makes its way to the
thoracic cavity (3). Although lymph nodes are spread throughout the lymphatic system,
they are more concentrated in the armpits, neck, groin, and chest areas (3).
2
The spleen, located in the abdominal cavity, is another element of the lymphatic
system. The purpose of the spleen is to filter blood for pathogens, remove old erythrocytes
and recycle iron from old erythrocytes. Like other components of the lymphatic system, the
spleen is comprised of lymphatic tissue. The lymphatic tissue in the spleen is flourished
with blood vessels, which are spread out into blood sinuses (3). The blood sinuses are
lined with macrophages whose purpose is to engulf pathogens that it encounters via
phagocytosis (3).
The thymus gland is an important component of the immune system and is
responsible for producing a type of lymphocytes called T Cells (4). The thymus glad is
located behind the sternum near the heart (4). T Cells are lymphocytes that have two
functions; some help the immune system, and thus they are called “Helper T Cells”, while
others have a direct impact and are called “Cytotoxic T Cells” (5). Helper T Cells help the
immune system by alerting other immune cells to an invader and instructing those cells to
create antibodies (5). Cytotoxic T Cells do not assist; instead they destroy invaders when
they come into direct contact with them (5).
Similar to the thymus gland, the bone marrow is also responsible for producing
immunological cells. The bone marrow is the tissue that is accountable for producing all
cells that are considered to be white blood cells including lymphocytes, monocytes,
granulocytes, neutrophils, eosinophils, and basophils (6). Lymphocytes have two forms: B
Cells and T Cells. T Cells were described previously, B Cells form antibodies to foreign
particles that enter the body helping fight off infection and disease (6). The ability to be
immune to a certain pathogen can be attributed to the work of lymphocytes. Once an
individual becomes infected by a pathogen, lymphocytes form antibodies to that pathogen
3
so that the body is able to recognize and fight off the pathogen should it encounter that
particular pathogen again. Monocytes are the immature form of macrophages, which are
responsible for engulfing and removing foreign particles (6). Granulocytes get their name
from the granules that are present within their cytoplasm and consist of neutrophils,
eosinophils and basophils (7). Neutrophils destroy bacteria and viruses, eosinophils
destroy parasites and basophils respond to allergens (6).
As mentioned previously, tonsils are another component of the lymphatic system.
Tonsils are composed of lymphatic tissue and are located on either side of the pharynx;
acting as filters to protect the body from pathogens entering the body via the upper
digestive and respiratory tract (3).
HL is one of the most common cancers among children and young adults and is
characterized by the presence of Reed-Sternberg cells, which are illustrated below in
Figure 1.2 (2). Reed-Sternberg cells cause the body’s lymphatic system to release
immunologic factors such as lymphocytes, macrophages and granulocytes, which comprise
tumors that are characteristic of HL.
Figure 1.2(8)
4
HL typically presents itself initially as a painless enlarged lymph node and as the
disease progresses it spreads further among lymphatic nodes and tissues. The nodes most
commonly affected by HL are localized among a group of nodes: cervical, mediastinal, and
para-aortic (2). The staging of HL is of great significance as the stage determines how it
should be treated. For example, individuals who are stage I-II are most often free from
systemic manifestations (2). However, once individuals progress to stages III-IV they begin
having symptoms such as drenching night sweats, weight loss and fevers (2). The stages of
the disease and the associated symptoms are shown below in Table 1.2. Upon the initial
diagnosis of B.T.’s HL, she was classified as stage IIIB.
Table 1.2 Clinical Stages of Hodgkin’s Lymphoma (2)
Stage I
Involvement of a single lymph node region or a single extra-lymphatic
organ or site
Stage II
Involvement of two or more lymph node regions on the same side of the
diaphragm alone or localized involvement of an extra-lymphatic organ or
site
Stage III
Involvement of lymph node regions on both sides of the diaphragm
without or with localized involvement of an extra-lymphatic organ or site
Stage IV
Diffuse involvement of one or more extra-lymphatic organs or sites with or
without lymphatic involvement
All stages are further divided on the bases of the absence or presence of the following
symptoms: unexplained weight fever, drenching night sweats, and/or unexplained weight
loss of great than 10% of normal body weight
Past Medical History:
Prior to the diagnosis of HL, B.T’s medical history was unremarkable, however it
was noted in her chart that she had undergone some surgeries since her diagnosis. The
surgeries were performed to remove lymph nodes that were affected by HL, but the exact
5
dates of those surgeries were not documented. B.T. had also undergone chemotherapy to
treat her HL and was receiving chemotherapy during the admission in which this study was
conducted.
Present Medical Status and Treatment:
The HL stage is very important when it comes to determining how invasive the
treatment should be. There are currently 5 different types of treatment options (9):
1. Chemotherapy- usage of drugs whose purpose is to stop the growth of cancer
cells
2. Radiation therapy- high energy x–rays used to either kill cancer cells or prevent
them from growing any further; radiation therapy can also be used internally
and is typically placed directly into a site where the cancer is located
3. Targeted therapy- treatment that uses drugs capable of identifying and targeting
cancer cells without harming normal cells
4. Surgery- surgical removal of tissues containing cancerous cells
5. High-dose chemotherapy with stem cell transplant – as it’s name implies, high
doses of chemotherapy drugs are given and stem cells are implanted to replace
cells that have been killed as a result of chemotherapy
As mentioned previously, B.T. was diagnosed with stage IIIB, a more advanced stage
of the disease. B.T. had also undergone surgery to remove the affected lymph nodes in her
neck and was also undergoing chemotherapy.
B.T. was admitted on the basis of back pain and neutropenia. The cause for her
radiating back pain was not made clear but was most likely secondary to cancer and/or
cancer treatment. The neutropenia was secondary to B.T.’s chemotherapy treatments. B.T.
6
received a neutropenic diet during her admission due to her neutropenia diagnosis and
also received an extensive amount of medications to control her symptoms. A list of B.T.’s
medications can be found in Appendix 1 (10).
In addition to B.T.’s observable signs and symptoms, it is also important to note her
laboratory values to help visualize symptoms that aren’t always apparent externally. Table
1.3 shows B.T.’s laboratory values with their reference ranges denoted in parenthesis.
Table 1.3 B.T.’s Laboratory Values (1/22)
Glucose
Sodium
Potassium
Chloride
BUN
Creatinine
Hemoglobin
Hematocrit
111 (70-99 mg/dL)
137 (135-145 mEq/L)
4.0 (3.5-5.0 mEq/L)
101 (101-111 mEq/L)
11 (5-20 mg/dL)
0.51 (0.5-1.1 mg/dL)
7.7 (12.0 - 16.0 g/dL)
25.4 (35-47%)
Glucose can be elevated during times of stress, which is definitely a factor to be
considered in B.T.’s case. Furthermore, glucose may also be elevated when individuals
receive steroids, which B.T. was receiving during her admission. These labs also reveal that
B.T.’s hemoglobin and hematocrit were decreased. This could be the result of the
chemotherapy treatment that she was receiving since chemotherapy stops the growth of
cells, including the bone marrow cells that are responsible for producing red blood cells.
Observable physical and psychological changes:
B.T. was asleep during the first visit and so all information was obtained thorough
B.T.’s mother. B.T.’s mother did not comment much on B.T.’s physical health; all that was
discussed was her nutrition. However, it was found in B.T.’s chart that she was not
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ambulating since she was in a lot of pain. During the second visit with B.T., she was awake
and alert and was able to answer all questions for herself. Like the first visit, nutrition was
the primary topic discussed. However, during the second visit B.T. stated that she was
having some troubles swallowing because her throat was sore, she was unaware of the
cause and that it wasn’t preventing her from consuming meals.
Treatment:
As mentioned previously, B.T. was admitted for back pain secondary to HL and so
her treatment focused mainly on medications to reduce pain. Also mentioned previously,
B.T. was admitted with neutropenia secondary to chemotherapy. Again, B.T. was receiving
a neutropenic diet to decrease the risk of infection from eating items such as raw food that
could carry harmful microorganisms that a healthy individual’s immune system could fight
off.
Medical Nutrition Therapy:
Nutrition History:
B.T. follows a neutropenic diet (avoidance of raw/undercooked food items) while
she is at home and her mother is responsible for grocery shopping and preparing meals.
B.T. and her mother eat all of their meals family style at a dining room table where a
television set is not visible. Two weeks leading up to B.T.’s admission, B.T. had not attended
school and so all meals had been prepared by her mother and had been eaten at home.
Table 1.4 shown below shows a summary of B.T.’s typical intake at home along with the
nutritional analysis of those food items. During the initial interview, a 24-hour recall was
also conducted to determine if B.T. was meeting her caloric needs while at the hospital.
B.T.’s 24-hour recall along with the nutritional analysis can be found below in Table 1.5.
8
Table 1.4: Nutrient Analysis for B.T.’s Typical Intake
CHO
Protein
1 cup frosted flakes
1 cup 2% milk
1 Ensure
34g
12g
40g
1g
5g
9g
¾ cup black beans
1 cup white rice
2 servings potato
chips
1 cup pre-packaged
fruit cocktail
29g
53g
Fat
Breakfast
Kcals
Fe
Ca
A
C
0g
12g
6g
140
120
250
25%
0%
25%
0%
29%
30%
10%
1%
25%
10%
0%
50%
11g
4g
1g
0g
169
228
10%
15%
4%
1%
0%
0%
0%
0%
30g
4g
20g
360
4%
0%
0%
20%
18g
1g
0g
76
0%
0%
2%
100%
1 Ensure
40g
9g
6g
250
25%
30%
25%
50%
1/3 cup white pasta
¼ cup pasta sauce
3 oz ground beef
½ cup cooked
broccoli
1 slice bread
1 can Pepsi
TOTAL
42g
7g
0g
6g
1g
23g
1g
1g
9g
201
41
173
10%
4%
14%
0%
2%
1%
0%
15%
0%
0%
8%
0%
5g
3g
0g
32
3%
5%
19%
61%
15g
41g
366g (64%)
2g
0g
80g (14%)
1g
0g
57g (22%)
77
164
2281
5%
0%
140%
3%
0%
105%
0%
0%
97%
0%
0%
299%
Lunch
Snack
Dinner
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Table 1.5: Nutritional Analysis for B.T.’s 24-Hour Recall
CHO
Protein
Fat
Kcals
Breakfast
Fe
Ca
A
C
Hard boiled egg
Breakfast Potato
Sausage Chicken
Patty
Turkey Bacon
Blueberry Muffin
Orange Juice
0
20
6
3
5
6
68
141
3%
0%
2%
0%
6%
0%
0%
0%
1
7
10
120
0%
2%
1%
0%
0
25
14
11
3
0
11
8
0
141
178
57
9%
7%
1%
0%
5%
0%
0%
1%
3%
0%
1%
71%
White Bread (2)
Tuna Salad
Provolone Cheese
Baked Potato
Chips
Mac & Cheese
Chocolate Chip
Cookie
Lipton Brisk diet
2 packet
mayonnaise
26
3
1
4
13
7
2
5
8
130
111
98
12%
11%
12%
4%
3%
23%
0%
4%
5%
0%
8%
0%
20
1
5
131
2%
4%
0%
0%
26
6
13
223
12%
9%
3%
0%
24
2
10
184
8%
2%
1%
1%
0
0
0
0
0%
0%
0%
0%
4
0
0
20
0%
0%
0%
0%
White bread (2)
Turkey (cooked)
Provolone Cheese
Fruit Cocktail
Chocolate
pudding
Pepsi
TOTAL
26
0
1
15
4
7
7
1
2
0
8
0
130
28
98
58
12%
2%
12%
4%
4%
0%
23%
2%
0%
0%
5%
10%
0%
2%
0%
8%
24
4
4
140
8%
6%
1%
1%
26
256 (45%)
0
86 (15%)
0
97 (40%)
96
2152
0%
115%
0%
89%
0%
40%
0%
92%
Lunch
Dinner
10
During the first visit B.T. consumed 100% of her meals equating to 2152 kcals and
86g protein based on the nutritional analysis of the 24-hour recall; meeting her daily
requirements for calories. B.T.’s requirements were calculated using her adjusted body
weight of 55.7 kg. Although using adjusted body weight in pediatrics is usually
contraindicated, it was necessary in this case as B.T.’s weight is >95% percentile, she is
obese and is 206% of her IBW (11). According to ASPEN, the equation for nutrient
requirements in childhood cancer for obese children uses a stress factor ranging from 1.51.6, which is then multiplied by the BMR using the child’s adjusted body weight (12).
Furthermore, ASPEN also states protein requirements for children with pediatric cancer
are 1.8g/kg/day (12). Since adjusted body weight was used to calculated caloric
requirements, adjusted body weight was also used to determine B.T.’s protein needs. The
calculations performed for B.T.’s caloric and protein requirements are shown below:
BMR (females) = [655 + (9.6 x wt (kg)) + (1.8 x ht (cm)) – (4.7 x age)] x Injury Factor
BMR = [655 + (9.6 x 55.7kg) + (1.8 x 154.5cm) – (4.7 x 17) = 1388 kcals
1388 kcals x (1.5-1.6) = 2082-2221 kcals/day
Protein = 1.8 x adjusted body wt
1.8 x 55.7 = 100g protein/day
Although B.T. did not consume enough protein to meet her needs during the first
visit (adjusted body wt x 1.5), she was consuming 100% of her meals and was consuming
adequate calories (BMR x 1.5) to meet her needs, so no acute nutrition related problems
were identified and a formal nutrition diagnosis was not made. Accordingly, per hospital
protocol, a follow-up was scheduled but an intervention was not performed. Since a
nutrition problem was not identified, there was not a specific aspect of her intake to be
11
monitored during follow up; it was scheduled simply to ensure B.T. did not develop any
nutrition related problems.
A 24-hour recall was not obtained during the second visit; however, during the
second visit B.T. was still consuming 100% of her meals. Based on the 24-hour recall from
the initial visit and the kcals calculated from B.T.’s typical caloric intake, it was assumed
B.T. was still consuming enough calories to meet her needs at that time and so, again, no
acute nutrition related problem was identified and a formal nutrition diagnosis was not
made. Similar to the first visit, a formal intervention was not made since a nutrition
diagnosis was not performed and a follow up visit was scheduled to continue to monitor
B.T.’s nutritional status.
Prognosis:
HL is considered to be one of the most curable cancers if diagnosed early enough in
the disease. The medical prognosis for HL depends on the stage at which it is diagnosed;
the earlier it is diagnosed, the less invasive the treatments. The cure rate for individuals
presenting with stages I and IIA is ~90%; with advanced disease (Stage IVA-IVB) the 5-year
survival rate is 60-70% (2). Based on these statistics, B.T.’s medical prognosis is difficult to
determine since she was diagnosed as Stage IIIB. Unfortunately individuals surviving HL
have an increased risk of developing other cancers such as lung cancer, breast cancer,
gastric cancer, sarcoma, and melanoma secondary to chemotherapy and radiation therapy
received to treat HL (2).
Cancer treatment can cause nutrition related side effects including: anemia,
neutropenia, electrolyte imbalance, constipation, diarrhea, malabsorption, dysphagia,
stomatitis/mucositits, dehydration, anorexia, dysgeusia, fatigue, weight loss, and pain (13).
12
The nutritional prognosis for B.T. is considered to be quite good since during the visit, B.T.
did not mention that she had any of the listed side effects other than neutropenia (at least
during that admission). It did not appear that B.T. had any problem with anorexia/weight
loss since she is considered to obese and did not have a problem consuming 100% of her
trays.
Summary and Conclusion:
Although there was not much I could do for B.T. because a formal nutrition
diagnosis was not made, I still learned a lot from B.T. Prior to this study I was not too
familiar with the pediatric population and was even more unfamiliar with cancer and the
nutritional implications of the disease. Cancer has always provoked great interest since it is
the second leading causes of death and because it has afflicted many in my family (14). I
found it very interesting to learn just how important nutrition’s role is in the fight against
cancer.
This case study was also very eye opening for me because prior to this I didn’t
realize just how sick so many children are. Prior to this internship I had an interest in going
into pediatric dietetics but then became unsure. This rotation has definitely reassured me
that pediatric nutrition is where my heart is. The future of our nation lies within our
children’s hands; it is our job as health care professionals to ensure our children are as
healthy as possible so that our nation as a whole will thrive.
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Appendix 1: Medications (10)
Medication
Purpose
Celecoxib
Pain Reliever
Cetirizine
Antihistamine
Clindamycin
Antibiotic
Famotidine
H2 Blocker
Ferrous Sulfate
Iron Supplement
B.T.’s Medications
Drug Interactions
ACE inhibitors,
angiotensin II receptor
blockers,
anticoagulants,
diuretics
Antidepressants, antianxiety medications,
antiepileptic,
tranquilizers
Erythrocin
Not to be taken with
other drugs that treat
GERD
Chloramphenicol,
cimetidine, levodopa,
methyldopa,
penicillamine,
cinoxacin,
ciprofloxacin,
demeclocycline,
doxycycline, enoxacin,
Nutrition Implications
Other Side Effects
Diarrhea, gas, weight
gain, loss of appetite
Sore throat, cold
symptoms
Dry mouth, stomach
pain, diarrhea,
vomiting
Drowsiness, excessive
tiredness
Nausea, vomiting,
heartburn
Joint pain, white
patches in mouth,
vaginal discharge
Diarrhea, constipation
Headache, dizziness
Constipation, stomach
upset
Constipation, stomach
upset
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levofloxacin,
oxytetracycline,
sparfloxacin,
Buprenorphine,
butorphanol,
ipratropium,
medications for:
glaucoma, IBD,
parkinsons disease,
ulcers, and uriniary
problems
Nausea, vomiting,
constipation, dry
mouth
Lightheadedness,
dizziness, drowsiness,
sweating, itching,
mood changes
Hydromorphone
Pain reliever
Bleomycin
Treats head and neck
cancer (HL)
Brentuximab, vedotin
Cyclophoshamide
Treats Hodgkin’s
Lymphoma
Alkylating agents,
allopurinol,
hydrocortisone
Doxorubicin
Treats Hodgkin’s
Lymphoma
Cytarabine,
dexrazoxane,
mercaptopurine,
streptozocin,
phenobarbital,
phenytoin
Nausea, vomiting, loss
of appetite, weight
gain, diarrhea,
increased thirst
Unusual tiredness or
weakness, dizziness,
hair loss, separation of
nails from nail beds,
burning on hands/feet
Etoposide
Treats Hodgkin’s
Lymphoma
Cisplatin, cyclosporine
Nausea, vomiting,
stomach pain, diarrhea,
constipation, loss of
Unusual tiredness or
weakness, pale skin,
fainting, hair loss,
Sores on
mouth/tongue,
vomiting, loss of
appetite, weight loss
Nausea, vomiting, loss
of appetite, diarrhea,
sores on the mouth,
should drink plenty of
water when taking this
medication
Redness & blistering of
skin, rash, hair loss,
darkened skin color
Changes in skin color,
sore throat, fever,
chills, hair loss
15
appetite, weight loss,
Filgrastim
Gabapentin
Ondansetron
Prednisone
Helps fight infection in
those with neutropenia
Lithium
Increased water needs
Anticonvulsant
Hydrocodone,
morphine, naproxen,
antacids
Nausea, vomiting, heart
burn, diarrhea,
constipation, increased
appetite, weight gain,
difficulty swallowing
Anti nausea for
chemotherapy
Treats multiple
symptoms, most
likely used for
the purpose of
pain relief in
B.T.
Apomorphine,
amidarone,
azithromycin, sotalol,
quinidine,
procainamide,
tramadol, thioridazine,
soltalol, erythromycin
Amiodarone,
anticoagulants,
antifungals,
ketoconazole, aspirin,
lovastatin,
phenobarbital, oral
contraceptives
burning on hands/feet
Bone,joint, or muscle
pain, fever, shortness
of breath, wheezing,
dizziness, hives, rash,
sweating, unusual
bruising
Drowsiness, tiredness,
dizziness, headache,
blurred vision, anxiety,
memory problems,
fever, itching, seizures
Constipation, diarrhea
Headache, drowsiness,
chills, fever, rash,
itching, shortness of
breath, fainting
Follow a low-salt, high
potassium, high
calcium diet, heartburn
Headache, dizziness,
extreme changes in
mood, thin, fragile skin,
increased hair growth,
acne, weak muscles,
increased sweating
16
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