Febrile Neutropenia as the Presenting Sign of Appendicitis in an Adolescent With Acute Myelogenous Leukemia

Abstract

The diagnosis and management of a surgical abdomen in patients with acute leukemia is quite difficult because of the complications and treatment of disease itself. A 13-year-old boy with acute myelogenous leukemia developed 2 episodes of febrile neutropenia during induction therapy. The second one was treated with a 5-day course of parenteral antimicrobial therapy, but the patient then presented with right lower quadrant abdominal tenderness, guarding, and rebound tenderness. Abdominal ultrasonography and computed tomography revealed appendicitis. Conservative medical management was unsuccessful, and appendectomy was performed 5 days after appendicitis was diagnosed. The patient's clinical manifestations resolved 5 days later. The case illustrates that fever may be the first manifestation of appendicitis in a child with acute myelogenous leukaemia who is neutropenic. Surgery is acceptable as first-line treatment in such cases.

Treatment of Appendicitis in Neutropenic Children

“…However, antibiotic therapy as sole treatment has been associated with longer hospital stays and does not address the continued risk of recurrent appendicitis. In addition, nonoperative management may not be successful [15]. In a series of five patients managed nonoperatively with antibiotics, three patients developed similar abdominal pain during later rounds of chemotherapy [1].…”

Treatment of Acute Appendicitis in the Patients With Severe Neutropenia

“…In contrast, medical therapy as the sole treatment has been associated with longer hospital stays and recurrent appendicitis or complications [7]. Acute appendicitis usually requires surgical intervention [7][8][9].…”

Acute appendicitis in adult neutropenic patients with hematologic malignancies

“…6 By contrast, acute appendicitis usually requires surgical intervention, even in neutropenic patients, because of high risk of severe and life-threatening complications such as perforation and peritonitis. [2][3][4]8,9 To the best of our knowledge, we report the first case of appendectomy in an adult patient undergoing autologous bone marrow transplantation, during the aplastic phase, without any abdominal or systemic complication. On the basis of our favorable clinical experience, though anecdotal, and on the data from the literature, [2][3][4]8,9 we support the feasibility, efficacy and safety of early appendectomy in neutropenic hematologic patients receiving chemotherapy even at high doses and presenting with an abdominal complication consistent with acute appendicitis.…”

“…[2][3][4]8,9 To the best of our knowledge, we report the first case of appendectomy in an adult patient undergoing autologous bone marrow transplantation, during the aplastic phase, without any abdominal or systemic complication. On the basis of our favorable clinical experience, though anecdotal, and on the data from the literature, [2][3][4]8,9 we support the feasibility, efficacy and safety of early appendectomy in neutropenic hematologic patients receiving chemotherapy even at high doses and presenting with an abdominal complication consistent with acute appendicitis. The diagnosis of acute appendicitis should be confirmed by early abdominal CT, which remains at present the best method, 5 whereas ultrasonography shows more limitations, with lower sensitivity and specificity.…”

“…2,3 Thus, even an accurate physical evaluation of the patient, without the support of imaging studies (abdominal CT or ultrasonography), may fail to diagnose this possibly life-threatening condition in this clinical setting, 4 whereas in immunocompetent adult patients, the increased use of preoperative abdominal CT has led to a sustained decrease in the rates of false-positive clinical diagnosis of appendicitis. 5 The early performance of abdominal CT, at the onset of symptoms, in immunocompromised patients may be also relevant for the differential diagnosis, especially of neutropenic enterocolitis or typhlitis.…”