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  • Introduction Acute acalculous cholecystitis ACC is

    2019-05-10

    Introduction Acute acalculous cholecystitis (ACC) is defined as an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis and has a multifactorial pathogenesis [1]. ACC has very rarely been described in patients undergoing myelosuppressive chemotherapy for acute myeloblastic leukemia (AML). As far as the latter patients are concerned, expecting severe neutropenia lasting for ≥10 days, ACC is associated with significant morbidity and mortality [2]. Clinical diagnosis of ACC remains difficult in these patients’ populations, but early diagnosis and intervention can boost prognosis. We present two AML patients that developed ACC during chemotherapy-induced neutropenia. Case report 1: A 21-year-old male was admitted to our hospital for AML. The patient started chemotherapy with cytarabine 200mg/m2 in a 24h infusion through days 1 to 7 and idarubicin 12mg/m2 (days 1,2,3). In neutropenic period, he noradrenaline developed invasive pulmonary aspergillosis treated with voriconazole and Stenotrophomonas maltophilia bacteremia that resolved with broad spectrum antibiotics. The bone marrow examination on the 25th days of induction showed persisting infiltration with 50% blasts. The patient, then, underwent a second course of induction chemotherapy with high dose of cytarabine 6g/m2 (days 1,2,3) and Metoxantrone 12mg/m2 (days 1,2,3). He received voriconazole during chemotherapy for secondary prophylaxis of probable invasive aspergillosis. On day 9 of the second course, he presented febrile neutropenia that has been aggravated by septic shock. Broad spectrum antibiotic regimen and intravenous crystalloid fluid were administered. The values of peripheral blood pressure responded well to fluids. Enterobacter cloacae were detected in peripheral blood. However, the patient was still febrile. On day 20, he was diagnosed with acute pain in the right upper quadrant accompanied by vomiting. His leukocyte count was 0.5×109/L and absolute neutrophil count was 0.0×109/L. C-reactive protein was 260mg/dL. His renal function was normal, and liver function tests result showed cholestasis without cytolysis. Abdominal ultrasonography was performed and demonstrated acalculous gallbladder with overdistention, wall thickening (up to 5mm). ACC was diagnosed and the medical therapy continued (broad spectrum antibiotic regimen, intravenous fluids, fasting). Nevertheless, the patient’s condition deteriorated and on the next day, he presented abdominal contracture. A second abdominal ultrasound demonstrated acalculous gallbladder with overdistention, wall thickening (up to 11mm) and pericholecystic fluid (Fig. 1). The patient was qualified for life-saving surgery. Open-cholecystectomy was performed after platelet concentrate transfusions. The intraoperative examination revealed a gangrenous acalculous cholecystitis that had reached the cystic duct and an under hepatic blade. Histopathological evidence demonstrated gangrenous cholecystitis. In the postoperative period, a broad spectrum antibiotic regimen, erythrocyte and platelet concentrate transfusions were continued. However, the patient was still febrile. Chest X-ray demonstrated an intensive bilateral pneumonia. Then, the patient presented a respiratory distress syndrome and he died on postoperative day 5. Case report 2: A 52 year old female was followed up at our hospital for AML. She was in remission after induction chemotherapy. The course was complicated by invasive pulmonary aspergillosis treated with Voriconazole. Then, she received a first course of consolidation. During neutropenic period, she presented a bacteremia to Burkhaldaria cepacia. The patient was treated with broad spectrum antibiotic. A second course of consolidation was administrated with cytarabine 200mg/m2 in a 24h infusion through days 1–7; daunorubicin 50mg/m2 (days 1,2,3) and etoposide 100mg/m2 in a 4-h infusion every 24h from day 1 to day 5. She received voriconazole during chemotherapy for secondary prophylaxis of probable invasive aspergillosis. Nine days after chemotherapy, the patient presented a febrile neutropenia with worsening diarrhea, intermittent nausea, vomiting, and acute abdominal pain. She received a combination of antibiotic therapy and imipenem, amikacin. Blood cultures were negative. She remained febrile. On the 21day after the start of chemotherapy, while the patient was under broad-spectrum antibiotic treatment, the symptoms recurred; fever accompanied by vomiting and acute pain in the right upper quadrant. Laboratory examination revealed the following results: C-reactive protein increased to 450mg/l, absolute neutrophil count was 0.0×109/L and platelets count 0.8×109/L, accompanied by elevated blood levels of cholestatic liver enzymes without cytolysis with a total bilirubin of 163 micromol [4–24µmol]. Abdominal ultrasonography and computer tomography confirmed the diagnosis of ACC by showing gallblader with overdistention, wall thickening (mm) and biliary sludge (Fig. 2). ACC was diagnosed, and the medical therapy was continued (broad spectrum antibiotic regimen, intravenous fluid, fasting). However, the patient’s condition deteriorated and noradrenaline she died by septic shock after 5 days of ACC diagnostic.