Cytarabine/idarubicin

Abstract

A 66-year-old man with acute myeloid leukaemia (AML) developed disseminated intra-abdominal aspergilloma with abdominal wall invasion during treatment with cytarabine and idarubicin [frequencies not clearly stated;duration of treatment to reaction onset not stated]; he subsequently died of septic shock.The man was diagnosed with AML and received induction chemotherapy with cytarabine 200 mg/m 2 for 7 days as a continuous infusion, and IV idarubicin 12 mg/m 2 for 3 days. Prior to chemotherapy, he reported continuous intractable nausea with bilious vomiting, which was unresponsive to antiemetics. These symptoms worsened after chemotherapy. Abdominal CT showed extensive ileitis and colitis. On day 14 after induction, bone marrow aspirate revealed an acellular bone marrow. The next day, he received granulocyte colonystimulating factor (G-CSF). He also developed neutropenic fever and received anti-bacterial and fluconazole, which was subsequently replaced by voriconazole. However, his condition did not improve and his nausea and vomiting persisted. He developed severe hypotension, which did not respond to fluid resuscitation, and he was transferred to an ICU. His pancytopenia continued. On day 30, bone marrow aspirate was still hypocellular. Five days later, his ANC started to increase. At the same time, a hard palpable abdominal mass was detected in his left upper quadrant. Abdominal CT findings showed a hypoattenuating region peripherally circumscribed by a thin enhancing rim of 6 × 5cm, which was in continuity with a region of the jejunal loop distention, total effacement of the bowel wall and dense infiltration of the surrounding fat; findings favoured aspergilloma over a leukaemic infiltrate. Biopsy revealed necrotic tissue enclosing septate branching hyphae, which were consistent with Aspergillus abscess.The man received liposomal amphotericin B. By day 45, his WBC count had recovered and laparoscopy revealed a large mass involving multiple jejunal loops and the surrounding transverse colon. He underwent dissection and excision of the mass, which required removal of a 7cm portion of the transverse colon and a 33cm portion of the jejunal loop. He underwent resection of the abdominal wall with clear margins. Histological analysis showed complete necrosis with hyphae consistent with Aspergillus. There was also evidence of steatonecrosis. He underwent reanastomosis of his small bowel and opening of the transverse colon to form a permanent colostomy. He did well postoperatively and was transferred to a chronic care facility. However, he was unable to afford medical care and subsequently died of septic shock, which was thought to be most likely due to a disseminated Aspergillus infection.Author comment: He received first-line 7 + 3 induction chemotherapy with idarubicin and high-dose cytarabine, which are both known to be capable of altering bowel integrity by disrupting the mucosal barrier and thus generating a new route of entry for uncommon pathogens such [as] Aspergillus."