CASE 2
Patient 2 was a 49 year old male with pre-B cell acute lymphoblastic
leukemia (ALL) who completed the first cycle of induction therapy (Hyper
CVAD) which was complicated by neutropenic fever and abdominal pain. A
CT revealed enlarged appendix with extensive adjacent inflammatory
stranding throughout the right lower quadrant consistent with
appendicitis (Figure 2). The patient was initially evaluated by general
surgery who determined that he was not a surgical candidate given severe
thrombocytopenia and neutropenia. He was transitioned to metronidazole
and levofloxacin after initial broad-spectrum antibiotics with
Piperacillin/Tazobactam. He later developed perforation with abscess and
lactic acidosis prompting an alternative antibiotic regimen, intravenous
(IV) ertapenem. A pelvic drain was placed and drain sample cultures
revealed extended spectrum beta-lactamase (ESBL) Escherichia
coli . The patient received a prolonged course of IV ertapenem and his
cell counts recovered prior to elective laparoscopic appendectomy. He
recovered, achieved CR1, and later received a myeloablative conditioning
regimen of cyclophosphamide and total body irradiation (Cy TBI) for
matched related donor allogeneic peripheral blood stem cell transplant.
He later developed veno-occlusive disease (VOD) and ultimately died of
treatment related mortality on day + 42.