Auckland District Health Board

Park Road
Private Bag 92 024
Auckland 1142
Telephone +64 9 307 4949
www.adhb.govt.nz

Clinic Letter
Paediatric Haematology Oncology
CR
[F404800130463]

Mercury Bay Medical Centre Date of Clinic 12/01/2022

87 Albert Street Date of Typing 13/01/2022
Whitianga ACC Number N/A
Date of Injury N/A

Copy to Patient Y

Dear Doctor

Re Jake Pokai NHI Number XBV0548

18 White Street Minor NHI
Whitianga 3510 DOB 11/04/2005
New Zealand Gender Male

Covid-19 Pandemic: Level Orange – Auckland 2021/2022

Primary Oncologist: Dr Mandy De Silva (Initially Dr David Deambrosis)

Nurse Specialist: Madeleine Rose

Diagnoses
1. T-Cell Acute Lymphoblastic Leukaemia
- Diagnosed 18/12/2020
- CNS status: CNS 1
- BCR-ABL gene rearrangement negative. End of induction MRD negative. Treatment
as per COG AALL1231. Commenced 20/12/2020
- Interim maintenance II Day 41, as per intermediate risk arm AALL1231
- EOT 10/5/2024

Other Diagnoses
1. Venous access: portacath in situ
2. PCP prophylaxis: Weekend cotrimoxazole
3. PEG asparaginase anaphylaxis – received erwinase
4. Platelet anaphylaxis, needs pre-med
5. Prolonged cytopenias
6. Fertility preservation performed 18/12/2020 and 21/12/2020.
7. LP’s under sedation in theatre (needs EMLA on his back an hour prior to this)

Cardiac Function
1. Normal cardiac function at diagnosis
2. Echo 18/12/2020
3. Echo pre DI normal EF/FS, but falling GLS
4. Echo following week 2 of DI
5. 19/08/2021 Echo FS 48%, EF 0.64, reduced cardiac volume, normal LV and RV
function, no pericardial effusion

Immune Status
Has received two doses of Covid-19 (pfizer) vaccine, will be due a third dose, but not when

Visit www.healthpoint.co.nz
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on steroids. This will be organised by his nurse specialist and the local GP informed.

Medications to be taken at home

1. Dexamethasone 5.5 mg in morning, and 5 mg at night for five days (ten doses)
- Start p.m. 13/01/2022, last dose a.m. 18/01/2022
2. 6-mercaptopurine 50 mg tablets: 2 ½ tablets (125 mg) Monday to Friday at night on an
empty stomach
- 3 tablets (150 mg) Saturday and Sunday nights on an empty stomach. Doses will be
adjusted according to full blood counts regularly
3. Methotrexate 35 mg (3 x 10 mg and 2 x 2.5 mg tablets) weekly on Thursdays, to start on
20/01/2022. Do not have this medication when you have an LP with IT MTX
4. Cotrimoxazole 2 x 480 mg bd Saturday and Sunday
5. Ondansetron 8 mg three times a day as required
6. Tazocin IV 4.5 g as emergency antibiotics in case of febrile neutropenia

It was a pleasure to see Jake in clinic again, accompanied by his father in Whitianga
College.
He is having a really good time living at the seaside, and now resembles a kiwi kid!
They are quite stressed about the family being apart in two countries, and of course this
causes major concern for everybody, but with Covid Omicron on the horizon, I cannot see
that this is going to change very quickly.

They are now enrolled at the local GP practice “Mercury Bay” in Whitianga.
I have copied this letter to Taumarunui GP practice.
If the Mercury Bay practice needs copies of the previous correspondence, I am sure the
previous GP practice can forward the whole file to them.

Jake has been well, but his counts have only just recovered in order to commence on
maintenance therapy, and were as follows when done in Whitianga yesterday:

Haemoglobin 115 g/L

White cell count 2.3 x 109 L
Neutrophils 1.2
Lymphocytes 0.6
Platelets 83
Creatinine 63 µmol/L
Bilirubin 6 µmol/L
ALT 17 U/L

We could discuss the overall plan for maintenance going forward, and I have made them a
systematic drawing which they have taken with them.
I have sent a prescription for all the new drugs which we have discussed, and
Madeleine Rose will catch up with them tomorrow again, to the Auckland City Hospital
pharmacy, as they can pick up the repeats in a month’s time; day 57 and after cycle 2 day
29 and 57, IV vincristine, oral dexamethasone and full blood counts will be managed by
Waikato with telephone communication with us, and he will only need to see us every third
month at Starship.

Danny was interested in buying an Oxygen sats monitor at our local pharmacy for them to
take back to Whitianga, which is probably a good idea.
They do have an emergency antibiotic pack with them, and have delivered the emergency
letters to the local GP’s rooms, and he will be due his third dose of Covid vaccine at some
stage mid cycle when not on steroid during his cycles of maintenance therapy.

Chemotherapy received on 13/01/2022 : M cycle1 d 1

Vincristine 2 mg IV
Methotrexate 15 mg IT.

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On examination today:
Weight was 66.1 kg,
Height 168.8 cm,
Temperature 36.2°,
BP 126/81,
SAO2 96% on room air,
Heart rate 105 bpm and
Respiratory rate 22.
His Karnofsky score is 100.
He is afebrile, with no signs of JACOL present.
His CVS is normal, and his chest is clear.
His abdomen is soft, non-tender, with no organomegaly or masses present.
He has good dorsiflexion of his ankles (more than 90°), but absent deep tendon reflexes of
knees.
His mouth and throat were fine.
He has no skin lesions, but has a really tanned skin at this stage.

I reminded them that he needed long sleeves and probably long pants, lots of sunscreen and
a hat when he spends his time in the sun and sea, as the methotrexate can exacerbate
sunburn, and he can develop a dry skin and rashes due to methotrexate.
He might also develop some acne on his face from the dexamethasone, but we do not
expect much steroid effect in putting on weight and swelling up of cheeks (cushingoid
symptoms), as he only has five days of dexamethasone every month.
I recommended good exercise, not having too much salt, increasing fluid intake and curbing
calorie intake caused by the dexamethasone if at all possible, to prevent cushingoid
symptoms.

In Summary
Jake is now commencing maintenance cycle 1 chemotherapy on marginal FBC.
He continues in 1st CR of his T ALL.
His FBC’s need to be repeated regularly and oral antimetabolites titrated accordingly.
Cycle 2 will consist of day one and day 29 LP’s in Auckland, and day 57 IV vincristine and
Full blood count in Waikato.
From maintenance cycle 3 onwards, he will only have an LP in Auckland on day one,
and visits to Waikato days 29 and 57 for IV vincristine .

Future Appointments
13/01/2022 Theatre with LP IT MTX IV VCR Maintenance cycle 1 day one
26/01/2022 Local laboratory, a full blood count with a nurse encounter from Starship
Blood and Cancer Centre
09/02/2022 Clinic from 27A, full blood count, creatinine, bili and ALT. This clinic visit is not
count dependant. This is for maintenance cycle 2 day 29
10/02/2022 Theatre, LP IT MTX IV vincristine
10/03/2022 Waikato Outreach Clinic with full blood count, IV vincristine, maintenance
cycle 1 day 57.

Thank you for sharing care of Jake with us.

Please feel free to contact us for any concerns

Kindest regards

Dr Ruellyn Cockcroft
Paediatric Oncologist
Starship Blood and Cancer Centre

This document is dictated and approved by the author

External cc
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XBV0548

Guardian/Parent of Jake Pokai Shared Care Waikato

18 White Street Email: PaediatricSharedCareOncologyWDHB@waikatodhb.health.nz
Whitianga 3510
[10ASAV-404800141001]

Dr Anna Teata
Taumarunui Medical Centre
28 Kururau Road
Taumarunui
Internal cc
[323005-304800141192]

Mandy De Silva
Paediatric Oncologist
SBCC - Medical
Starship Children’s Health

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