Background And Aims: Invasive fungal infections (IFI) in children with newly diagnosed acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) are poorly characterized, especially in lower-middle income countries (LMICs). This study aims to identify the incidence, risk factors and outcomes of IFI in a pediatric cohort with ALL/LBL. Methods: We retrospectively analysed pediatric patients diagnosed with ALL/LBL between January and December 2023 at a tertiary cancer center in India. Patients were risk-stratified and treated per the modified ICiCLe protocol. IFIs were classified as proven, probable and possible according to the revised EORTC/MSG consensus definition. Results: Among 407 patients, 392 (96%) had ALL. The overall incidence of IFI was 24%, with probable/proven infections in 12%. Mold infections predominated (79 cases, 77%), followed by yeast infections (21 cases, 21%). In comparison to patients without IFIs, those with IFIs were more likely to have received dexamethasone (30% vs 20%; p=0.009) and anthracycline (28% vs 14%; p=0.001) during induction. Chemotherapy interruptions occurred in 56% of IFI cases, impacting treatment continuity. The 6-week mortality rate of patients with IFI was 15%, rising to 26% in probable/proven cases. Coexisting bacterial infection was associated with increased mortality (odds ratio: 19.2[95%CI: 3.5-105]; p=0.001). Conclusion: IFIs are common in newly diagnosed ALL/LBL patients in LMICs, particularly during early phases of therapy. These infections are associated with considerable mortality, often compounded by concomitant bacterial sepsis. Given these findings, consideration of antifungal prophylaxis is warranted to mitigate morbidity and mortality due to IFIs.

Background: Even though rituximab has emerged as the standard of care for management of high risk paediatric burkitt lymphoma(BL) its safety in children from the low-middle income countries(LMICs) remains to be proven. We herein report our experience of using rituximab in patients with BL treated in our institute. Patients and Methods: All patients diagnosed of BL between January-2015 through December-2017 were treated in a risk stratified manner with either modified MCP-842 or modified LMB protocol. Patients with poor response to MCP 842 were shifted to LMB-salvage regimen. In addition, rituximab was given for selected patients of LMB group B or C. Result: Forty-two(49.4%) of 85 analyzed patients with BL received rituximab [Median dose:1500(Range:375-1875) mg/m2]. The incidence of febrile neutropenia(p=0.02), pneumonia(p=0.005), Intensive care unit admissions(p=0.002) and toxic deaths(p=0.04) were higher amongst BL patients who received rituximab. Pneumonia was fatal in 11 of 16(69%) patients who received rituximab. The mortality was 100% for patients who developed recurrent pneumonia after completion of treatment. On multivariate analysis, rituximab continued to be significantly associated with toxic deaths, HR:11.45(95%CI: 1.87-70.07; p=0.008). The addition of rituximab to intensive chemotherapy resulted in an inferior 1-year event free survival (49.4±8.1% vs 79.3±6.5%;p=0.025) and 1-year overall survival (63.1±8.5% vs 91.8± 4.5%;p=0.007). Also, the addition of rituximab did not improve 1-year relapse free survival (78.3±7.3% vs 83.9±6.0%;p=0.817). Conclusion: The potential immunomodulatory effect of rituximab and increased susceptibility to infections in patients from LMICs being treated under resource-constrained situations has to be carefully considered while choosing this drug in the treatment BL.