Typhlitis as the initial presentation of acute lymphocytic leukemia - A case report

We report a case of typhlitis as the initial presentation of adult acute lymphocytic leukemia (ALL). A forty-five year old man presented with fever, right lower quadrant pain and diarrhea. On admission the hemogram revealed 67% blast cells in the peripheral blood. A cytochemical study confirmed a diagnosis of ALL. The absolute neutrophil count dropped to 117 three days later. Abdominal computerized tomography showed that the colon was swollen on the right side with an abnormally thickened wall and infiltrations in the pericolic fat. Stool analysis was positive for occult blood and Giardia lamblia. Typhlitis complicating ALL was considered and empirical antibiotics (ceftazidime and metronidazole) which covered Gram negative bacilli, anaerobic bacteria and Giardia lamblia were instituted. The typhilitis symptoms improved and a follow-up abdominal MRI study showed complete resolution of right side colon disease. Standard chemotherapy for ALL (vincristine, daunorubicin, L-asparaginase, prednisolone and intrathecal methotrexate) was given. Unfortunately the patient died after a sudden onset of ventricular fibrillation during an episode of pneumonia. We suggest that typhlitis may present as an initial manifestation of ALL and Giardia lamblia may play a role in its pathogenesis.