Acute myelogenous leukemia and acute leukemic appendicitis: a case report.
ABSTRACT Acute myelogenous leukemia (AML) can involve the gastrointestinal tract but rarely involves the appendix. We report a male patient who had 1 year partial remission from AML and who presented with apparent acute appendicitis as the initial manifestation of leukemia relapse. Pathological findings of the appendix revealed transmural infiltrates of myeloblasts, which indicated a diagnosis of leukemia. Unfortunately, the patient died from progression of the disease on the 19th d after admission. Although leukemic cell infiltration of the appendix is uncommon, patients with leukemia relapse can present with symptoms mimicking acute appendicitis.
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ABSTRACT: Key Clinical MessageA case of appendiceal involvement by acute myeloid leukemia (AML) in an adult with recent history of AML transformed from myelodysplastic syndrome (MDS) was presented. Being aware of this rare presentation in particular in a patient with history of MDS and/or AML is important for prompt clinical diagnosis and management.Clinical Case Reports. 09/2014;
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ABSTRACT: Appendicitis in leukemic patients is uncommon but associated with increased mortality. Additionally, leukemic cell infiltration of the appendix is extremely rare. While appendectomy is the treatment of choice for these patients, diagnosis and management of leukemia have a greater impact on remission and survival. A 59-year-old Caucasian female was admitted to the surgical service with acute right lower quadrant pain, nausea, and anorexia. She was noted to have leukocytosis, anemia, and thrombocytopenia. Abdominal imaging demonstrated appendicitis with retroperitoneal and mesenteric lymphadenopathy for which she underwent laparoscopic appendectomy. Peripheral smear, bone marrow biopsy, and surgical pathology of the appendix demonstrated acute myeloid leukemia (AML) with nonsuppurative appendicitis. In the setting of AML, prior cases described the development of appendicitis with active chemotherapy. Of these cases, less than ten patients had leukemic infiltration of the appendix, leading to leukostasis and nonsuppurative appendicitis. Acute appendicitis with leukemic infiltration as the initial manifestation of AML has only been described in two other cases in the literature with an average associated morbidity of 32.6 days. The prompt management in this case of appendicitis and AML resulted in an overall survival of 185 days.Case reports in hematology. 01/2013; 2013:815365.
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ABSTRACT: Abdominal pain is common during chemotherapy for childhood leukemia. Clinically differentiating typhlitis from appendicitis can be difficult. We present an 8-year-old boy with abdominal pain in the setting of acute lymphoblastic leukemia and neutropenia. Following appendectomy for presumed appendicitis, pathology revealed appendiceal typhlitis. Diagnostic and treatment considerations are discussed.Pediatric Surgery International 01/2014; 30(5). · 1.06 Impact Factor
Acute myelogenous leukemia and acute leukemic
appendicitis: A case report
Po-Jen Hsiao, Shih-Ming Kuo, Jia-Hong Chen, Hsuen-Fu Lin, Pau-Ling Chu, Shih-Hua Lin, Ching-Liang Ho
Online Submissions: wjg.wjgnet.com
firstname.lastname@example.org World Journal of Gastroenterology ISSN 1007-9327
doi:10.3748/wjg.15.5624 © 2009 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol 2009 November 28; 15(44): 5624-5625
Po-Jen Hsiao, Pau-Ling Chu, Shih-Hua Lin, Division of
Nephrology, Department of Internal Medicine, Tri-Service
General Hospital, National Defense Medical Center, 114 Taipei,
Shih-Ming Kuo, Division of Pediatric Surgery, Department
of Surgery, Tri-Service General Hospital, National Defense
Medical Center, 114 Taipei, Taiwan, China
Jia-Hong Chen, Hsuen-Fu Lin, Ching-Liang Ho, Division of
Hematology/Oncology, Department of Internal Medicine, Tri-
Service General Hospital, National Defense Medical Center,
114 Taipei, Taiwan, China
Author contributions: Hsiao PJ, Kuo SM, Chen JH, Lin HF,
Chu PL, Lin SH, and Ho CL contributed equally to this work;
Hsiao PJ and Kuo SM wrote the paper.
Correspondence to: Dr. Ching-Liang Ho, Division of Hemato-
logy/Onology, Department of Internal Medicine, Tri-Service
General Hospital, National Defense Medical Center, No. 325,
Sec. 2, Chenggong Road, Neihu District, 114 Taipei, Taiwan,
Telephone: +886-2-87923311-13524 Fax: +886-2-87927379
Received: August 14, 2009 Revised: October 14, 2009
Accepted: October 21, 2009
Published online: November 28, 2009
Acute myelogenous leukemia (AML) can involve the
gastrointestinal tract but rarely involves the appendix.
We report a male patient who had 1 year partial re-
mission from AML and who presented with apparent
acute appendicitis as the initial manifestation of leu-
kemia relapse. Pathological findings of the appendix
revealed transmural infiltrates of myeloblasts, which
indicated a diagnosis of leukemia. Unfortunately, the
patient died from progression of the disease on the
19th d after admission. Although leukemic cell infiltra-
tion of the appendix is uncommon, patients with leu-
kemia relapse can present with symptoms mimicking
© 2009 The WJG Press and Baishideng. All rights reserved.
Key words: Acute myeloid leukemia; Appendicitis;
Appendectomy; Granulocytic sarcoma
Peer reviewer: Mr. Morten Hylander Møller, Department of
Anaesthesiology and Intensive Care Medicine, Copenhagen
University Hospital Herlev, Skolevej 14B, Holte 2840, Denmark
Hsiao PJ, Kuo SM, Chen JH, Lin HF, Chu PL, Lin SH,
Ho CL. Acute myelogenous leukemia and acute leukemic
appendicitis: A case report. World J Gastroenterol 2009;
15(44): 5624-5625 Available from: URL: http://www.wjgnet.
com/1007-9327/15/5624.asp DOI: http://dx.doi.org/10.3748/
Acute myeloid leukemia (AML) affects middle-aged
adults. When the disease involves soft tissue, it is called
granulocytic sarcoma (GS). GS can present in the
gastrointestinal tract but involvement of the appendix is
uncommon. Furthermore, infiltration of the appendix
by leukemic cells is also a rare manifestation of leukemia
relapse. Herein, we report a 75-year-old man with AML-M2
who had been in partial remission for 1 year, and who
presented with symptoms mimicking acute appendicitis as
the initial manifestation of leukemia relapse. Subsequent
pathological examination confirmed the diagnosis.
A 75-year-old man was admitted for evaluation of
right lower quadrant abdominal pain and fever for 3 d.
He had partial remission of AML-M2 for 1 year, after
chemotherapy with low dose cytarabine. His past
history included hypertensive cardiovascular disease
with congestive heart failure, coronary artery disease,
and chronic obstructive pulmonary disease. Physical
examination showed rebound tenderness over the right
lower quadrant. The leukocyte count was 35 × 103/L,
with 15% neutrophils, 26% lymphocytes, 1% monocytes,
2% eosinophils, 0% basophils, and 56% immature cells.
Hemoglobin and platelet counts were 9.9 g/dL and 64 ×
103/µL, respectively. C-reactive protein was 7.98 mg/dL.
Abdominal computed tomography showed thickening of
the appendiceal wall and periappendicular fat stranding
(Figure 1). The diagnosis of acute appendicitis was
made, and appendectomy was performed immediately
after admission. Grossly, the appendix was gray in color
and soft in consistency. Microscopically, the sections
showed transmural infiltrates of myeloblasts, which
were positive for myeloperoxidase, CD43 and CD34
immunohistochemical stains (Figure 2). Hence, AML-M2
with involvement of the appendix was diagnosed.
Thereafter the patient received chemotherapy with low-
Hsiao PJ et al. Acute leukemic appendicitis 5625
dose cytarabine (20 mg/kg for 12 d). However, he died
from progressive disease complicated by septic shock and
acute respiratory failure on the 19th d after admission.
The incidence of GS is estimated to be 3% in living adult
patients with AML and 4.7% in children[1,2]. Rappaport
initially introduced the concept of acute lymphoblastic
leukemia infiltrating the appendix. In a review of
the literature, AML involving the appendix has been
described[1,3,4]. As a presentation of AML in adults, GS can
involve various sites throughout the body but it is rare in
the gallbladder and appendix. Bowel infiltration by leukemic
cells, described initially in the 19th century, was thought to
be a rare condition until autopsy studies in the 1960s and
1970s, which indicated a prevalence of this presentation in
10% to 53.3% of leukemia patients[5-8]. It has been reported
that appendiceal involvement by leukemic cells occurs in
approximately 3 of 36 patients (8.3%). Seven leukemia
patients with involvement of the appendix, including our
own, were identified in the literature. The survival time
varied as shown in Table 1[1,4,6].
Surgical management of patients with leukemia and
acute abdomen has not been advocated because of the high
rate of operative mortality in the past[4,6]. However, there is
some support for surgical management of appendicitis in
acute leukemia as the most effective method of therapy[1,4,9].
Systemic chemotherapy is necessary in this setting for
additional radiation or surgery in patients with GS.
In conclusion, we report a rare case of AML who had
been in partial remission for 1 year and presented with
symptoms of acute appendicitis as the initial manifestation
of leukemia relapse. Although leukemic cell infiltration
into the appendix is uncommon, our case highlights the
importance of differential diagnosis of acute appendicitis
including recognition of possible leukemic involvement.
The physicians should be aware of these conditions.
Müller G, Dargent JL, Duwel V, D'Olne D, Vanvuchelen J,
Haot J, Hustin J. Leukaemia and lymphoma of the appendix
presenting as acute appendicitis or acute abdomen. Four
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Pui MH, Fletcher BD, Langston JW. Granulocytic sarcoma
in childhood leukemia: imaging features. Radiology 1994;
Rappaport H. Tumors of the hematopoietic system, in Atlas
of Tumor Pathology, Section III, Fascicle 8. Washington DC:
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Toubai T, Kondo Y, Ogawa T, Imai A, Kobayashi N, Ogasawara
M, Kiyama Y, Higa T, Sato K, Miyokawa N, Tanaka J, Imamura
M, Kasai M. A case of leukemia of the appendix presenting as
acute appendicitis. Acta Haematol 2003; 109: 199-201
Askanazy M. Über akute Leukämie und ihre Beziehung zu
geschwürigen Prozessen im Verdauungskanal. Arch Pathol
Anat Physiol Klin Med 1894; 137: 1-24
Prolla JC, Kirsner JB. The gastrointestinal lesions and
complications of the leukemias. Ann Intern Med 1964; 61:
Cornes JS, Jones TG. Leukaemic lesions of the gastro-
intestinal tract. J Clin Pathol 1962; 15: 305-313
Viadana E, Bross ID, Pickren JW. An autopsy study of the
metastatic patterns of human leukemias. Oncology 1978; 35:
Kim KU, Kim JK, Won JH, Hong DS, Park HS. Acute
appendicitis in patients with acute leukemia. Korean J Intern
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Shaikh BS, Frantz E, Lookingbill DP. Histologically
proven leukemia cutis carries a poor prognosis in acute
nonlymphocytic leukemia. Cutis 1987; 39: 57-60
S- Editor Wang JL L- Editor Cant MR E- Editor Lin YP
Figure 1 Abdominal computed tomography reveals appendicular wall
thickening and periappendicular fat stranding.
Figure 2 Cross-section of the appendix specimen. A: Leukemia involving the
appendix is characterized by transmural infiltrates of myoloblast cells (HE, × 200);
B: These tumor cells are immunoreactive to myeloperoxidase protein (HE, × 200).
No.Sex/ageType TreatmentSurvival time (d)
7 (Our case)
Hours to days
M: Male; F: Female; NA: Not available.
Table 1 Seven cases of leukemia infiltration of the appendix
described in the literature