br Comments The present two cases developed ACC during chemo

Comments The present two cases developed ACC during chemotherapy induced neutropenic for AML. ACC is a relatively rare complication in these patients’ population. It’s reported in 0.4% among all neutropenic episodes of patients with acute leukemia or aggressive lymphoma undergoing myelosuppressive chemotherapy [3]. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. Diagnosis of ACC may be further prolonged until the patient’s general condition worsens as a consequence of gallbladder necrosis or perforation, as our two cases. Ultrasound is an established valuable imaging method if cholecystitis is suspected [4]. Computed tomography can be extremely useful in the assessment of septic shock of unknown origin in this patient population [4]. In the present two cases, we observed several factors that were most likely responsible for ACC. These included chemotherapy, neutropenia, fasting, fever, diarrhea and bacteremia. The latter factors induced intracystic hemorrhage followed by sudden exacerbation, which resulted in gangrenous cholecystitis followed by perforative biliary peritonitis [2]. Similar finding was observed in our first case report. Voriconazole recommended for treatment of invasive aspergillosis, were associated with significant increasing toxic adverse effect. Cholecystitis was reported in few patients exposed to voriconazole medication [5]. Our two patients were treated with voriconazole during the course of chemotherapy. Voriconazole might have increased the risk of cholecystitis in our two patients. The two prevailing treatment options for AAC are cholecystostomy and/or cholecystectomy [2]. However, there was a hot debate as to its optimal effectiveness in the treatment of ACC. Consequently, Cholecystostomy does not offer a survival benefit compared with cholecystectomy or no surgical interventions in patients with ACC [6]. Several studies have found improved outcomes in patients with cholecystectomy compared with patients without surgical management [6]. Early cholecystectomy eliminated the potential infection foci, and reduced the risk of ongoing sepsis and multi-organ failure [2]. In our first case, the ultrasound image was suggestive of gall order Ro 3306 necrosis, with biliary perforation and this was confirmed in intraoperative. In the second case, the operation wasn’t performed urgently, and the patient died by septic shock. These two presented cases confirm that ACC can progress into a very serious condition with high risk of mortality if gangrene and perforation developed.
Conclusion
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Acknowledgements
Introduction Acute myeloid leukemias (AML), stratified into different risk categories based on cytogenetic and biomolecular analysis, respond differently to therapeutic interventions implemented for curative intent. Overall, most AML patients have complete remission but 40% commonly relapse during the first three years [1]. It occurs most often in the bone marrow (BM) but central nervous system (CNS) involvement is not rare as its incidence ranges between 2% and 9% [2]. CNS leukemia can present as meningeal leukemia, cranial nerve palsies or cerebral mesenchymal myeloid sarcoma [3]. Peripheral neuropathy may also be a puzzling manifestation as it is a common complaint in clinical practice with a very wide differential diagnosis.
Case presentation We report the case of an otherwise healthy 69 year-old female patient that presented to our department for a new onset of persistent disabling fatigue and 10% weight loss over two months. She had no prior medical problems and did not complain of any other symptoms. On clinical exam, the patient was afebrile, hypotensive with a blood pressure of 90/50mmHg, and tachycardic at 140beats/min. Her initial labs showed hemoglobin 3g/dL, white blood cells 114.000×109/L with 80% blasts, platelets of 15.000×109/L, LDH of 773U/L, SGOT of 1400U/L and SGPT of 1416U/L. She had increased PT and PPT with low fibrinogen level suggestive of disseminated intravascular coagulation. Qualitative RT-PCR on BM cytology revealed the presence of CBFβ-MYH11 transcript type D (chromosome 16 inversion), and FLT3p.D835V mutation confirming an acute myelomonocytic leukemia (AML/M4). BM cytogenetic analysis using R banding revealed a translocation between chromosomes 5 and 12, 46,XX,t(5;12)(p13;p13). Accordingly, the patient underwent 3+7 induction chemotherapy with cytarabine (100mg/m2 continuous infusion days 1–7) and idarubicin (9mg/m2 days 1–3) although she only received a single dose of the latter because of her abnormal liver function tests. Analysis of her BM one month later showed complete cytologic remission with persistence of CBFβ-MYH11 fusion transcript. The patient received thereafter three consolidation cycles with high-dose cytarabine. Complete molecular response was obtained three months later.