Treatment Emergent Agranulocytosis with Skin and Gingival Lesions in a Chronic Lymphocytic Leukemia Patient: A Case Report

Abstract

Chronic Lymphocytic Leukaemia (CLL) is a monoclonal lymphoid malignancy characterized by progressive accumulation of small, mature but functionally incompetent neoplastic lymphocytes in the peripheral blood, bone marrow and lymphoid organs. Patients present a variable course and may not require early intervention unlike other malignancies. Patients with rapidly deteriorating blood counts, and organomegaly need treatment. Alkylating agent live Bendamustine combined with Rituximab, anti-CD 20 monoclonal antibody have shown promising results in such patients. Anaemia, neutropenia and thrombocytopenia have been reported as treatment emergent events with this combination therapy. Neutrophils are the major innate defense and their depletion can result in a wide range of opportunistic infections. This case report discusess the oral and dermal lesions which emerged with the Rituximab and Bendamustine combination therapy in a patient with CLL and their management.

Gingival Necrosis Related to Sepsis-Induced Agranulocytosis Due to Pseudomonas aeruginosa Bacteraemia: A Case Report

“…Further characteristics of agranulocytosis-related gingival necrosis are described in Table 2 and Table 3 . Agranulocytosis may be triggered by drugs [ 6 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], and it commonly occurs in immunocompromised patients [ 13 , 14 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ]. Common systemic signs include fever, malaise, nausea, vomiting, lymphadenopathy, pharyngitis, dysphagia, sepsis [ 37 , 48 ], and septic shock [ 13 , 36 , 43 ], and it may result in death [ 14 , 44 , 45 , 48 ].…”

“…Other studies report the use of empirical broad-spectrum antibiotics and/or antifungals [ 6 , 36 , 37 , 38 , 39 , 41 , 42 , 44 , 45 , 49 , 50 ] and substituted them later if cultures were performed [ 13 , 14 , 43 , 47 , 51 ]. Topical treatments include antiseptics [ 6 , 13 , 36 , 37 , 38 , 39 , 40 , 46 , 48 , 49 , 50 , 51 ], antibiotics [ 46 ], or antifungals [ 39 , 42 , 44 , 46 , 51 ] and analgesics [ 6 , 42 , 48 ] for pain management. Periodontal instrumentation and removal of necrotic tissues, sequestra, and excessively mobile teeth is usually performed when blood counts are deemed safe, and if the zone of necrosis is not too extensive [ 13 , 36 , 37 , 38 , 39 , 40 , 42 , 46 , 49 , 50 ].…”

“…Topical treatments include antiseptics [ 6 , 13 , 36 , 37 , 38 , 39 , 40 , 46 , 48 , 49 , 50 , 51 ], antibiotics [ 46 ], or antifungals [ 39 , 42 , 44 , 46 , 51 ] and analgesics [ 6 , 42 , 48 ] for pain management. Periodontal instrumentation and removal of necrotic tissues, sequestra, and excessively mobile teeth is usually performed when blood counts are deemed safe, and if the zone of necrosis is not too extensive [ 13 , 36 , 37 , 38 , 39 , 40 , 42 , 46 , 49 , 50 ]. When possible, drugs that are the suspected cause of decreased blood counts are discontinued or substituted [ 6 , 36 , 37 , 38 , 39 , 40 , 42 , 49 ].…”

Generalized gingival necrosis in a patient under methimazole use

“…1,2 Table 1 summarizes the findings in the literature that relate neutropenia or agranulocytosis with comorbidities and opportunistic clinical manifestations. 2,11,12,[15][16][17][18][19] The treatment of agranulocytosis with oropharyngeal infection usually involves the use of antibiotics, corticosteroids, and granulocytic colony stimulators. 2 In the present case, antimicrobial therapy was recommended, as well as replacement of methimazole (20 mg/day) with propylthiouracil (100 mg 8/8 h), ambulatory monitoring, guidelines for recognizing signs of immunosuppression and seeking medical assistance.…”

“…Thus, the connective tissue disintegrates and rampant necrotizing gingival lesions can occur in the oral cavity, 11 and severe neutropenia can progress to sepsis and death 1,2 . Table 1 summarizes the findings in the literature that relate neutropenia or agranulocytosis with comorbidities and opportunistic clinical manifestations 2,11,12,15–19 …”