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.