In this report we focus on the importance of an accurate diagnosis of gastrointestinal complications during
chemotherapy for
acute myeloid leukemia. The leukemic infiltrtion of the digestive system may cause mucosal
ulcers which can lead to
bleeding or perforation. The immune system deficiency in this cohort of patients may result in necrotic
enterocolitis (leukemic
typhlitis), perianal
inflammation,
abscesses, and
peritonitis. We describe a 37-year old male who presented in June 2004 with 2-month history of
fever, weakness and
sore throat, treated with
antibiotic therapy. Physical examination demonstrated palor. The peripheral blood count at admittance was as follow:
Hemoglobin 87 g/l, WBC 63 x 10(9)/l, and platelets 56 x 10(9)/l. The peripheral blood differential count showed: myeloblasts 4%, polymorphonuclear neutrophils (PMN) 20%, monocytes 60%, lymphocytes 16%. The diagnosis of
acute myeloid leukemia (AML) was confirmed by bone marrow aspirate, which presented an almost total infiltration by monocytoid blasts, AML type M5 according to FAB classification. Immunophenotypic evaluation by flow cytometry showed that the blast cells reacted with
antibodies to CD33, CD13, CD14, CD64, CD15, cytogenetics showed normal karyotype. Induction treatment consisting of
cytarabine 2 x 200 mg intravenously in push on days 1-8, vepeside 200 mg i.v. on days 1-5,
adriblastine 90 mgon days 1,3 and 5. On day 15 of
chemotherapy the patient got
fever 38.5 degrees C,
abdominal pain and
diarrhea (10 stools daily). Broad-spectrum
antibiotic therapy with
ceftriaxone and
amikacin was promptly instituted but condition worsened,
abdominal pain extended to all abdomen while the
fever and
diarrhea persisted. Ultrasonography on day 18 documented bowel wall thickness of
colic tract, part of duodenum and jejunum. Owing to suspicion of
neutropenic enterocolitis,
antibiotic therapy intensified with
teicoplanin,
fluconazole,
metronidazole and
pipril. Patient was neutropenic and thrombocytopenic, although daily
platelet transfusion from a single donor were given. We started with
granulocyte colony stimulating factor (
G-CSF) 5 g/kg, which was adiminstered for 7 days. After 7 days neutrophil value reached 1 x 10(9)/l, but
fever persisted, abdominal distension and
diarrhea progressively improved. The
fever peristed and
central venous catheter was removed on day 30. After removal of the
catheter the patient was getting better: the
fever disappeared. The blood count showed Hb 91 g/l, WBC 3,4 x 10(9)/l, platelet 114 x 10(9)/l and normal leukocyte differential count. We emphesize the importance of collaboration between the hematologist and the surgeon in monitoring gastrointestinal complications during and after
chemotherapy for acute
leukemias and value of abdominal ultrasonography evaluation.