Single-session therapeutic plasma exchange as salvage therapy for pegaspargase-induced severe acute pancreatitis accompanied by multiple organ dysfunction in a pediatric patient with B-cell precursor acute lymphoblastic leukemia: a case report.

Abstract

Background: Pegaspargase-related severe acute pancreatitis (SAP) combined with persistent multiple organ dysfunction syndrome (MODS) is a life-threatening adverse reaction in children receiving acute lymphoblastic leukemia (ALL) chemotherapy. Standard intensive supportive care often fails to halt progressive organ damage, while clinical data regarding therapeutic plasma exchange (TPE) as a rescue intervention in pediatric populations remain scarce. Guidelines released by the American Society for Apheresis (ASFA) do not recommend routine TPE administration for all patients diagnosed with acute pancreatitis.

Methods: This retrospective analysis describes a 7-year-old female patient newly diagnosed with B-cell precursor ALL, who developed SAP and refractory MODS 48 h after pegaspargase infusion. SAP diagnosis complied with the 2012 Revised Atlanta Classification, and MODS severity was quantified using the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) scoring system. After 24 h of maximum standardized supportive care failed to reverse clinical deterioration, a single standardized TPE session was implemented. A chronological care timeline and serial laboratory biomarker table were constructed to quantify the dynamic therapeutic response of the patient.

Results: Non-invasive ventilation was applied to relieve intractable respiratory distress; invasive mechanical ventilation and vasopressor support were unnecessary throughout hospitalization. Severe epigastric pain disappeared within six hours after TPE, and respiratory support was successfully withdrawn 24 h post-intervention. Significant declines in pancreatic enzyme levels, extreme hypertriglyceridemia and systemic inflammatory mediators were observed, alongside full recovery of respiratory, renal and hematologic organ function. No adverse events linked to apheresis occurred during treatment. The patient recovered completely from pancreatitis, resumed scheduled maintenance chemotherapy, and maintained minimal residual disease (MRD)-negative hematologic remission at the 3-month outpatient follow-up. Clinical improvement was mainly attributed to extracorporeal clearance of triglycerides and pro-inflammatory cytokines; due to the pharmacokinetic characteristics of pegaspargase at 48 h post-administration, the removal of this chemotherapeutic agent via TPE was negligible.

Conclusion: Single-session TPE can rapidly reverse refractory MODS triggered by pegaspargase-induced SAP when conventional supportive treatments show no efficacy. Nevertheless, complete clinical recovery cannot be solely attributed to apheresis, as continuous multi-organ supportive management was provided throughout the treatment course. TPE can be regarded as a targeted rescue strategy for carefully selected critically ill pediatric patients, yet existing meta-analyses and ASFA consensus statements do not support its universal routine use. Large-scale prospective pediatric cohort studies are required to determine the optimal timing and treatment cycles of TPE.