C. albicans appendicitis in a neutropenic patient after induction chemotherapy

A 62-year-old white man with a past medical history of hypertension and essential thrombocytosis diagnosed 17 years ago presented at our institution. He was being treated with hydroxyurea, with which he required occasional blood transfusions and platelets were controlled around 400 10/L range. Over a 2-month period, he developed gradually worsening exertional dyspnea, fatigue, decreased appetite, lost about 8 lb in weight. He was found to be pancytopenic, with a total white cell count of 3.26 10/L (normal, 3.8-10.6 10/L), his hemoglobin level was 7.9 gm/dL (normal, 12.9-16.9 gm/ dL), and his platelet count, 46 10/L. A bone marrow aspirate and biopsy revealed 100% cellularity, approximately 8%-10% CD34 positive blasts, and numerous atypical and hypolobated dysplastic megakaryocytes with increased reticulin fibrosis. He was diagnosed with myelofibrosis with underlying myeloproliferative disorder, which seemed to be progressing into a more accelerated phase. He was admitted for induction chemotherapy with cytarabine and idarubicin as a bridge to a matched allogeneic stem cell transplant. He completed 3 days of cytarabine 100 mg/m and 7 days of idarubicin 12 mg/m via a Hickman central venous indwelling catheter. On day 7 of the treatment, as his absolute neutrophil count dropped to 0.9 10/L, he was started on prophylactic ciprofloxacin 500 mg p.o. BID, and acyclovir 400 mg p.o. TID. Fluconazole was held due to mild hyperbilirubinemia (total bilirubin, 2.2 mg/dL [normal, 0.3-1.5 mg/dL]). On day 11, he spiked a fever of 100.5°F when his absolute neutrophil count was 0.4 10/L (normal, 0.8-3.6 10/L). He was started on cefepime; 2 days later, intravenous vancomycin was added as he continued to have intermittent fevers. He was asymptomatic and had no obvious source of infection. His intravenous catheter site appeared clean and nontender, and his blood and urine cultures were negative as was his chest X-ray. However, as he continued to have intermittent high-grade fevers up to 102.5°F, despite broad spectrum antimicrobials, consultation was sought from the infectious disease physician. On day 15, he was started on voriconazole 400 mg BID. The results of an Aspergillus galactomannan antigen test was negative (0.1; reference range, 0.5). On day 18, the patient developed mild right lower quadrant abdominal pain associated with mild dyspnea at rest. On examination, he was in mild distress due to pain. His blood pressure was 114 /80 mmHg; heart rate, 80 beats/min; respiratory rate, 28 breaths/min; pulse oximetry, 94% on 2-liter nasal cannula oxygen. His lungs were clear to auscultation. The patient was mildly tender in right lower quadrant with mild guarding but no rebound tenderness. Bowel sounds were present. A computed tomography (CT) scan of abdomen and pelvis with contrast showed a dilated appendix up to 1.3 cm in diameter with surrounding fat stranding suggestive of acute appendicitis. No fluid collection or dilated bowel loops were noted (Figure 1). A CT scan of the chest with contrast showed multiple bilateral lung nodular opacities; the largest one in the right middle lobe, was 3 cm in size. The patient underwent emergency laparotomy and appendectomy, which revealed the presence of an inflamed appendix adherent to the right pelvis side wall, with no gross evidence of tumor. On gross pathological examination, the vermiform appendix showed roughened serosal surface with fibrous adhesions. The appendiceal wall was thickened and focally hemorrhagic. Grey-tan exudate was noted within the lumen. No gross perforation was identified. Histological sections showed an Manuscript received April 22, 2013; accepted May 6, 2013. Correspondence Rohtesh S. Mehta, MD, MPH, MS, Division of Hematology/Oncology, UPMC Cancer Pavilion, Room 463, 5150 Centre Avenue Pittsburgh, PA 15232 (mehtars@upmc.edu). Disclosure The authors have no disclosures. Commun Oncol 2013;10:244-246 © 2013 Frontline Medical Communications DOI: 10.12788/j.cmonc.0032 Letters Case Letter