Medicalpractice版 - Help needed: 15yoF AML now with multi liver abscesses, not responding to Abx. |
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d******g
发帖数: 258 | 1 Difficult case to discuss and to seek suggestions, please help!
15yo female with recent dx AML-M1 s/p DAE chemo in 8/15, twice IAE chemo in
9/15, BM biopsy noted for CR. Patient had fever, abd pain, and black stool
during the immune suppression state from the first chemo, improved after
antibiotics. All symptoms recurred with the last chemo and not responding
well to antibiotic, transferred to tertiary hospital after 40days treatment.
Ruled out intracranial infection, found to have multiple liver abscesses
and pneumonia. Liver biopsy grows MSSA, Histo noted for a few Gram negative
bacilli, possible Acinetobacter baumannii. Treated with multiple antibiotics
including Ceftriaxone, linezolid, Imipenem, vancomycin, Levaquin, still
spike fever. ID consult recommended for Amphotericin B + Meropenem+
linezolid+ Tigecycline, the fever and liver abscesses on imaging showed
improvement, but still has intermittent fever. The fever responds to small
dose steroid or Acetaminophen very well. Now on Linezolid + Zosyn.
The liver abscess showing decreasing size in the CT scan but still with
multiple small abscesses, and seems forming sacs, which makes the
antibiotics harder to penetrate. Repeat BM biopsy showed recurring AML, only
able to give IA chemo x4days due to liver toxicity.
Patient has matched bone marrow, family is eager to do the transplantation.
Question is:
1. Why still spiking the fever? Any other cause? Any other exam or
medication to use?
2. Now the AML is coming back but patient can’t have the full chemo
regimen or transplantation due to the active infection and liver damage. Any
other treatment available for this situation?
Please let me know if you need more information. Thanks a lot. | e******e
发帖数: 118 | 2 I have seen a similar case, mid age Asian female w AML, s/p induction in
remission but could not complete consolidation chemo due to many liver
lesions- abscess per image study, multiple biopsy and cultures but not
revealing, treated w many antibiotics and antifungal. don't remember if she'
s febrile then. Eventually discharged home w po antibx, observe for AML and
images to follow up liver change. had a discussion with one of the ID
attending at MDACC who thought the liver lesion might be autoimmune
phenomenon rather than infection. She is now off antibx and her AML is still
in remission.
In your case, the fever might be due to AML. I think it's reasonable to
continue the antibiotics because he has positive culture result and liver
lesions seems responded. I would treat his AML while he's covered w
antibiotics. but I am not familar with pediatric regimen of AML, best to
discuss with his pediatric oncologist. |
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