Contemporary management of perianal conditions in febrile neutropenic patients

Anorectal Infections in Neutropenic Leukemia Patients: A Common Clinical Challenge

Anorectal infections in neutropenic leukemia patients are a significant and potentially life-threatening complication. The pathogenesis of this condition is not entirely understood and believed to be multifactorial, including mucosal injury as a result of cytotoxic drugs, profound neutropenia and impaired host defense. Establishing an early diagnosis is key and often made clinically on the basis of signs and symptoms, but also from imaging studies demonstrating perianal inflammation or fluid collection. The management of anorectal infections in neutropenic leukemia patients is not straightforward, as there are no well-conducted studies on this entity. This review seeks to provide a framework into the pathophysiology and clinical presentation of anorectal infections in neutropenic leukemia patients, propose a diagnostic approach and to discuss controversies in the management of this condition.

The Risk of Rectal Temperature Measurement in Neutropenia

BACKGROUND

Avoiding rectal thermometry is recommended in patients with neutropenic fever. Permeability of the anal mucosa may result in a higher risk of bacteremia in these patients. Still, this recommendation is based on only a few studies.

METHODS

This retrospective study included all individuals admitted to our emergency department during 2014-2017 with afebrile (body temperature <38.3°C) neutropenia (neutrophil count <500 cells/microL) who were over the age of 18. Patients were stratified by the presence or absence of a rectal temperature measurement. The primary outcome was bacteremia during the first five days of index hospitalization; the secondary outcome was in-hospital mortality.

RESULTS

The study included 40 patients with rectal temperature measurements and 407 patients whose temperatures were only measured orally. Among patients with oral temperature measurements, 10.6% had bacteremia, compared to 5.1% among patients who had rectal temperature measurements. Rectal temperature measurement was not associated with bacteremia, neither in non-matched (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.07-1.77) nor in matched cohort analyses (OR 0.37, 95% CI 0.04-3.29). In-hospital mortality was also similar between the groups.

CONCLUSIONS

Patients with neutropenia who had their temperature taken using a rectal thermometer did not experience a higher frequency of events of documented bacteremia or increased in-hospital mortality.

Risk Factors for Neutropenic Sepsis Related Mortality in Children Undergoing Allogenic Hematopoietic Stem Cell Transplantation

We aimed to analyze infections in children undergoing hematopoietic stem cell transplantation (HSCT) until engraftment. The spectrum and risk factors associated will help plan interventions to reduce mortality. We performed a retrospective analysis on the infections, associated risk factors, and mortality until engraftment in children up to 18 years of age undergoing HSCT from January 2017 to August 2020. A total of 399 children were included, with a male: female ratio of 1.9:1, with matched related donor HSCT in 36.6%, a matched unrelated donor in 18.3%, and haploidentical HSCT in 38.1% of children. Culture positive bacteremia was documented in 22.1% transplants with gram-negative bacteria (GNB) isolated in 71/88 (80%). Among the GNB, the predominant organism was Klebsiella pneumonia in 38 (53%), E.coli in 16 (22%), Pseudomonas in 9 (12%). Carbapenem resistance was documented in 24/71 (33%). The incidence of possible, probable, and proven fungal infections in the cohort was 63 (15%), 28 (7%), and 6 (1.5%), respectively. Mortality up to engraftment due to sepsis in our cohort is 3.3% (n = 13). There was a significant association between mortality and a perianal focus (30.8%, p value 0.029) and the presence of carbapenem resistance (38%, p value 0.002). Mortality among those who developed proven fungal infections was significantly higher than those with bacteremia (p value 0.004). Our study has identified fungal sepsis and carbapenem-resistant GNB sepsis as high-risk groups for mortality. Risk directed interventions in these groups would help ensure survival and optimal outcomes.

Gastrointestinal Surgical Emergencies in the Neutropenic Immunocompromised Patient

Surgeons encounter neutropenic patients through elective or emergency consultation with increasing regularity. As medical management continues to extend the lives of patients with benign hematologic diseases, hematologic malignancies, solid malignancies, or iatrogenic neutropenia, more patients are presenting with infectious complications caused and/or complicated by their neutropenia. This leaves surgeons in the difficult position of managing medically fragile patients with unusual presentations of common disease processes. These patients often fall outside of classical guidelines and treatment pathways. Many studies addressing these issues are retrospective and non-randomized. Here, we review common emergency gastrointestinal surgery scenarios and their management in the setting of a neutropenic patient. While biliary disease, appendicitis, anorectal disease, and perforations will be covered in detail, an extensive appreciation of a patient's medical or oncologic disease course and appropriate utilization of consultants such as interventional radiology, gastroenterology, and hematology is often necessary.

Anorectal Abscess in a Patient with Neutropenia and Refractory Acute Myeloid Leukemia: To Operate or not to Operate?

BACKGROUND Anorectal infections occur in 5% to 9% of patients with hematological malignancies, including acute myeloid leukemia, and cause febrile neutropenia and sepsis. Surgical treatments of anorectal abscesses tend to be avoided in patients with leukemia owing to persistent neutropenia and bleeding risks. CASE REPORT A 56-year-old man presented with an ischiorectal abscess. Preoperative laboratory test results revealed leukocytopenia and anemia. He was diagnosed with acute myeloid leukemia. He developed septic shock. Antibiotic treatment was ineffective, and fever persisted. One week later, the abscess was treated by incision and drainage. Two days later, induction chemotherapy was initiated. No pus was drained; cellulitis spread to both buttocks. Pain worsened, and oxycodone was administered. Achievement of complete remission failed. Reinduction therapy was started, followed by fistulotomy of the abscess with extensive debridement of cellulitis on day 6. Granulation was observed on day 17. The patient's fever resolved on day 21. Although hematopoietic recovery was observed, bone marrow examination demonstrated partial remission. Two additional courses of chemotherapy were administered. Abscess recurrence was not observed, even during febrile neutropenia. The surgical wound shrank to a skin defect along the gluteal cleft. He achieved complete remission and was transferred to another hospital, where he underwent 3 allogeneic stem cell transplants. He died of leukemia progression. CONCLUSIONS Surgical treatments can prevent fatal progression of anorectal abscess, even during neutropenia. Incision and drainage are suitable for fluctuant abscesses. For a non-fluctuant abscess aggravated by sepsis and cellulitis, it is worth considering more invasive surgical interventions, including debridement and fistulotomy.

Treating Porcine Abscesses with Histotripsy: A Pilot Study

Infected abscesses are walled-off collections of pus and bacteria. They are a common sequela of complications in the setting of surgery, trauma, systemic infections and other disease states. Current treatment is typically limited to antibiotics with long-term catheter drainage, or surgical washout when inaccessible to percutaneous drainage or unresponsive to initial care efforts. Antibiotic resistance is also a growing concern. Although bacteria can develop drug resistance, they remain susceptible to thermal and mechanical damage. In particular, short pulses of focused ultrasound (i.e., histotripsy) generate mechanical damage through localized cavitation, representing a potential new paradigm for treating abscesses non-invasively, without the need for long-term catheterization and antibiotics. In this pilot study, boiling and cavitation histotripsy treatments were applied to subcutaneous and intramuscular abscesses developed in a novel porcine model. Ultrasound imaging was used to evaluate abscess maturity for treatment monitoring and assessment of post-treatment outcomes. Disinfection was quantified by counting bacteria colonies from samples aspirated before and after treatment. Histopathological evaluation of the abscesses was performed to identify changes resulting from histotripsy treatment and potential collateral damage. Cavitation histotripsy was more successful in reducing the bacterial load while having a smaller treatment volume compared with boiling histotripsy. The results of this pilot study suggest focused ultrasound may lead to a technology for in situ treatment of acoustically accessible abscesses.

Perianal sepsis in neutropaenic patients with haematological malignancies: the role of magnetic resonance imaging and surgery

BACKGROUND

Perianal sepsis occurs in up to 10% of neutropaenic patients with haematological malignancy and is associated with significant morbidity and mortality. The management of this condition is challenging in neutropaenic patients due to its atypical pathophysiology. The aim of this study is to assess the role of magnetic resonance imaging (MRI) and surgery in neutropaenic patients with perianal sepsis.

METHODS

A retrospective chart review was performed on all neutropenic patients with a haematological malignancy who had a diagnosis of perianal sepsis during the inpatient admission between 2008 and 2017. Patient characteristics, symptoms, haematological data, MRI result, surgical intervention, intraoperative findings and outcomes including recurrence and mortality were collected.

RESULTS

Nineteen neutropaenic patients with haematological malignancy were treated for perianal sepsis, eight (42%) patients were managed conservatively and 11 (58%) were managed surgically. Nine patients underwent MRI, which identified a collection in 88% of cases despite severe neutropaenia. In patients with a collection identified on MRI prior to surgery, 80% had a drainable collection confirmed intraoperatively. Post-operative complications included two cases of sepsis from a presumed perianal source and one death. A total of 82% of patients experienced symptom resolution after surgery compared to 88% of patients managed conservatively.

CONCLUSION

This study has demonstrated that MRI is a useful diagnostic tool in evaluating perianal sepsis in patients with haematological malignancy, even during periods of severe neutropenia. We found that both conservative and surgical management strategies lead to resolution of symptoms.

A Novel Severity Score Index for Febrile Neutropenic Patients with Colorectal Diseases

Introduction

Abdominal and anorectal disorders may be the cause of clinical decompensation in neutropenic febrile patients, particularly those with hematologic diseases. Infection is a cause for concern for the colorectal surgeon. Some conditions have few manifestations and can lead to death within a short period of time. This study presents the novel colorectal disorder severity score for febrile neutropenic patients.

Materials and Methods

This was a case series study analyzing the medical records of 897 patients admitted to the Hematology and Hematopoietic Stem Cell Transplant Unit in a university hospital between the years 2008 and 2013. Seventy-four episodes of febrile neutropenia in 69 patients diagnosed with an abdominal or anorectal infection site were eligible for the study. The new scoring system proposed here is based on the author's clinical experience and an extensive literature review. In addition to the extensive literature review, effect measures were calculated, and a statistical analysis was performed. Based on an evaluation of common biological plausibility criteria, five factors were selected as the main predictors of hospital mortality in febrile neutropenic patients with colorectal disease.

Results

The proposed score demonstrated increased mortality as the condition worsened as reflected by an increasing score (Fisher's exact test: 0.001). When considering the logistic model for the probability of death by score level, the AUC value was 0.82 (0.72-0.925), and the Hosmer-Lemeshow statistic value was 2.3, p = 0.806.

Conclusion

The proposed scoring system allows prediction of the likelihood of death during hospitalization for febrile neutropenic patients with an abdominal and anorectal focus. New studies on the subject are required, and the proposed scoring scale must be validated on a larger and different sample of patients.

Hematopoietic Stem Cell Transplantation From Unrelated Donors in 2 Cases of Interleukin-10 Receptor Deficiency: Is Surgery Not a Requirement?

Mutations in interleukin-10 and its receptors cause infantile inflammatory bowel disease (IBD), a hyperinflammatory disorder characterized by severe, treatment-refractory colitis, multiple abscesses, and enterocutaneous fistulas. Patients with infantile IBD often require several surgical interventions, including complete colectomy, and hematopoietic stem cell transplantation is currently the only known medical therapy. Traditionally, operative management has been preferred before stem cell transplantation because of the latter's increased susceptibility to procedural complications; however, surgical intervention could be delayed, and possibly reconsidered, because our 2 patients with infantile IBD demonstrated a rapid response to treatment via engraftment.

Anorectal complications in patients with haematological malignancies

BACKGROUND

Anorectal complications are common in patients with haematological malignancies.

OBJECTIVES

The objectives are to characterize anorectal complications in these patients, identify risk factors and shed light on treatment, morbidity and mortality rates.

PATIENTS AND METHODS

A retrospective, observational study that included 83 inpatients with haematological malignancies and proctological symptoms from January 2010 to September 2015 was conducted. Clinical outcomes were obtained through a detailed review of medical records.

RESULTS

The median age was 56 years, and 52 (62.7%) patients were men. Fifty-six (67.5%) patients had nonseptic anorectal complications and 27 (32.5%) patients had septic anorectal complications.

RISKS FACTORS

Patients with septic anorectal complications were more commonly male, older, and had lower absolute neutrophil counts, but the differences were not statistically significant (P=0.79, 0.67 and 0.89, respectively). In positive blood cultures [23/70 (32.9%)], Enterococcus faecium, Klebsiella pneumonia, and Escherichia coli were the most common isolated agents.

TREATMENT

In nonseptic anorectal complications, conservative treatments/minor proctological procedures were adopted, and patients with septic anorectal complications were treated with antibiotics±major proctological procedures and/or surgical drainage/debridement.

RESULTS OF TREATMENT

Forty-eight (85.7%) patients in the nonseptic complications group improved compared with 23 (85.2%) patients in the septic complications group. The overall mortality rate was 2.4% (n=2), with one (1.2%) death related to perianal sepsis.

CONCLUSION

Enterococcus spp. were more commonly identified in this study and can be increasing in this specific population. In contrast to other reports, we did not identify an association between septic anorectal complications and possible risk factors such as male sex, younger age or a low absolute neutrophil count. Most patients had nonseptic anorectal complications. A major proctological procedure/surgical debridement should always be applied in septic complications, which have better prognoses now than in the past.

Typical MR imaging findings of perianal infections in patients with hematologic malignancies

OBJECTIVE

We aimed to investigate the MR imaging findings of patients with hematologic malignancies who have symptoms suggesting perianal infection and to demonstrate the importance of imaging.

SUBJECTS AND METHODS

The study included 36 patients with hematologic malignancies who underwent anorectal MR imaging in our department between September 2011-May 2016. Two radiologists experienced in abdominal radiology viewed the MR images in consensus. Abscesses, fistulous or sinus tracts, signal alterations and contrast enhancement in keeping with an inflammation and edema in the perianal region were recorded.

RESULTS

Perianal abscess was found in 16 of the 36 patients. In 10 of these 16 patients there was also extensive inflammatory signal alterations in perianal and/or perineal soft tissues. In six of the 36 patients perianal fistula was detected. A sinus tract was seen at the level of subcutaneous external anal sphincter in one patient. Inflammatory signal alterations in the surrounding soft tissues were present in three of these seven patients. There were abscesses in labium majus in two patients and in one patient there were perineal abscesses with accompanying inflammatory signal alterations. In six of the 36 patients no abscess or fistula/sinus tract was seen. There were only inflammatory signal alterations with contrast enhancement in perianal or subcutaneous tissues. In two patients presenting with perianal pain and hemorrhoids, minimal inflammatory changes were detected on MR images. There were two patients with normal MR imaging findings.

CONCLUSION

As digital examination of the anorectum and rectoscopy are avoided in neutropenic patients, MR imaging, which clearly demonstrates the perianal pathology should be preferential.

How to treat severe infections in critically ill neutropenic patients?

Severe infections in neutropenic patient often progress rapidly leading to life-threatening organ dysfunction requiring admission to the Intensive Care Unit. Management strategies include early adequate appropriate empirical antimicrobial, early admission to ICU to avoid any delay in the diagnostic and therapeutic management of organ dysfunction. This review discusses the main clinical situations encountered in critically ill neutropenic patients. Specific diagnostic and therapeutic approaches have been proposed for acute respiratory failure, shock, neutropenic enterocolitis, catheter-related infections, cellulitis and primary bacteriemia. Non anti-infectious agents and recent advances will also be discussed. At present, most of large-scale studies and recommendations in neutropenic patients stem from hematological patients and will need further validation in ICU patients.