Unexpected diagnosis of appendicitis in a paediatric patient with febrile neutropaenia and acute myeloid leukaemia

Abstract

DescriptionA 3-year-old boy with M7 acute myeloid leukaemia was admitted for induction chemotherapy with cytarabine, daunorubicin and etoposide. Two days later, he developed febrile neutropaenia and was started on cefepime. Blood cultures showed no growth and the fevers abated. Three weeks later, while still neutropaenic and receiving cefepime, the fevers recurred and persisted for 3 days with a maximum fever of 39.8° C. Antibiotics were changed to vancomycin and meropenem. He was non-toxic appearing without localising symptoms. He had occasional decreased appetite and loose stools, but he did not have abdominal pain, tenderness, masses or vomiting.Due to the persistent fevers, a CT scan of the chest, abdomen and pelvis was ordered which showed an acute appendicitis with abscess formation (figure 1). Appendectomy demonstrated acute necrotising appendicitis on pathological review without evidence of leukaemic involvement. He recovered well and became afebrile. Eight days later, fevers without abdominal symptoms recurred. Repeat CT scanning showed a large abscess in the right lower quadrant (figure 2). This was subsequently drained and cultures grew Pseudomonas. He received cefepime, metronidazole, tobramycin and filgrastim and subsequently recovered. He was discharged home when his neutrophil counts recovered 11 days later.The images shown demonstrate how large intra-abdominal processes can hide in the patient with neutropaenia. Due to the neutropaenia and lack of inflammatory immune responses, typical peritoneal signs were absent. His benign abdominal examination and continued oral intake were not suggestive of an intra-abdominal process at either time point, and without timely imaging, these infections could have progressed. Learning points► Intra-abdominal processes such as typhilitis, enterocolitis and appendicitis can be lifethreatening complications in patients with neutropaenia necessitating early diagnosis and intervention.1 2 ► In a patient with neutropaenia, such as one receiving intensive chemotherapy for leukaemia, persistent fevers despite broadspectrum intravenous antibiotic administration can warrant imaging, particularly of the abdomen and pelvis, because prolonged neutropaenia can mask the localising signs of infection by decreasing the inflammation that produces pain. In this case, dramatic imaging findings were found despite minimal abdominal symptoms.

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

“…Acute appendicitis can, albeit rarely, be life-threatening, in particular, if overlapping with typhlitis, as seen in our cohort with one fatality and reported in the literature 2 – 4 . Our study shows that abdominal pain is almost always found in patients with acute appendicitis, but the method of choice for diagnosis is imaging with ultrasonography, because abdominal pain may be absent during prolonged periods of neutropenia as seen in one of our patients and anecdotally reported by others 13 . Clinical differentiation of acute appendicitis and typhlitis is hardly possible and both may well occur together, as also observed in our cohort.…”

Unexpected diagnosis of acute lymphoblastic leukemia in a 2-year-old with acute appendicitis – Case report

“…Appendicitis is the most common abdominal emergency requiring surgery with a lifetime risk of about 7% with peak incidence in the late teens and early twenties [ 1 , 2 ]. Acute appendicitis is a known complication of treatment for hematologic malignancies, with a reported incidence of 0.5% to 4.4%, but involvement of the appendix with leukemic cells is rare [ [3] , [4] , [5] , [6] , [7] , [8] , [9] ]. Even more rare is the identification and diagnosis of ALL as a result of a clinical presentation of acute appendicitis.…”