Diagnosis and management of acute appendicitis in 21 pediatric hematology and oncology patients at a tertiary care cancer center

Abstract

Acute appendicitis is a rare gastrointestinal complication of anti-cancer chemotherapy and hematopoietic stem cell transplantation. Among a cohort of 2341 hemato-oncologic patients at a pediatric tertiary care cancer center, we identified 21 patients (0.9%) with 23 episodes of acute appendicitis, based on pathological imaging of the appendix and clinical findings. Median age at diagnosis was 10.21 years. Types of underlying disease included acute leukemias (n = 15), solid tumors (n = 4), and aplastic anemia (n = 2). Clinical symptoms seen in > 1 case were recorded for all 23 episodes as follows: abdominal pain, n = 22; abdominal tenderness, n = 4; fever, n = 7; nausea, n = 2; emesis; n = 2; diarrhea, n = 5; and constipation, n = 2. Median leukocyte count at diagnosis was 0.5 × 109/L, with a median of 0.1 × 109/L for the absolute neutrophil count (ANC). All patients received broad-spectrum antibiotics and 18/23 (78%) patients underwent uneventful appendectomy after a median of 5 days and with a median ANC of 0.7 × 109/L. Median duration until continuation of chemotherapy was 17 days for the 20 cases of appendicitis occurring during the patients’ disease course. Overall, 5/21 (19%) patients died including one related to the appendicitis itself which progressed to a typhlitis and was due to a fungal infection. The other fatalities were transplant- (n = 2) and leukemia-related (n = 2). Acute appendicitis is a rare and usually not life-threatening event in pediatric hemato-oncologic patients, which, if managed by prompt administration of broad-spectrum antibiotics (and antimycotics), can be safely followed by an elective (delayed) appendectomy, even before complete recovery of the neutrophils is achieved.

Acute Appendicitis in Children with Hematological Malignancies: The Need for Early Diagnosis and Prompt Treatment—A Single-Center Case Series

“…The incidence of leukemic infiltration of the appendix is negligible as shown by others; none of the patients had leukemic infiltration of appendix in our cohort ( Table 3 ). 12 13 14 It is difficult to diagnose appendicitis in immune-compromised patients with leukemia due to the absence of typical signs and symptoms. 8 9 15 Timely diagnosis of appendicitis is key to improving overall survival in these children.…”

Escalated doses of methotrexate and L‐asparaginase in critically ill children with a concurrent diagnosis of acute lymphoblastic leukemia and appendicitis

“…All patients suspended chemotherapy for 2-3 weeks, with a median of 17 days. 12 Since 1980 Capizzi described that a 24-h interval between methotrexate and a subsequent dose of asparaginase permits an additive therapeutic effect. 7 This regimen is mainly used in the consolidation or maintenance phases; there are no reports on the use of the Capizzi regimen in induction of remission; therefore, complications of TLS have not been described.…”