Multiple abdominal lesions secondary to ALL (ESGAR 2010 Case of the day)

Clinical History

A 15-years-old girl with acute lymphoid leukemia (ALL) became septic with toxic shock a few days after conclusion of inductive therapy. Lab tests revealed pancytopenia, progressive anemia and elevated WBC count without atypia. Chest radiogram showed bilateral hydrothorax. Abdominal-pelvic CT was performed to identify possible source of the septic/toxic condition.

Imaging Findings

Fig. 1 to 5: abdominal contrast-enhanced CT scans reveal multiple small hypodense round-shaped, partly ill-defined, partly rim-like lesions in the liver, the spleen and the kidneys with significant and characteristic thickening of the large bowel wall.

Discussion

Acute lymphoblastic leukemia (ALL) is a malignant (clonal) disease of the bone marrow in which early lymphoid precursors proliferate and replace the normal hematopoietic cells of the marrow. ALL itself and its therapy (inductive: Prednisolon, Vincristin, Daunorubicin, Asparaginase + 3x intrathecal Methotrexate) are often associated with severe immune-compromised condition, which may be complicated with various infections, some of them caused by opportunistic organisms (bacteria, fungi) and toxic shock (high fever, nausea, vomiting, abdominal pain and rectal bleeding). Appropriate cultures, in particular blood cultures, should be obtained in patients with fever or with other signs of infection without fever.
In our case CT revealed multiple hypodense, ill-defined focal abscess-like lesions in the liver and the spleen, associated with the hypodense thickening and thumbprinting of the entire large bowel (without signs of intramural hemorrhage). These were caused by a mixed E. coli + fungal infection, which reacted well to antifungal-antibiotic therapy and the patient recovered well after about two weeks and could receive the next series of treatment.

Differential Diagnosis List

Final Diagnosis

Septic embolisation/abscesses in the liver/spleen, inflammatory thickening of bowel wall.

URL:	https://www.eurorad.org/case/8944
DOI:	10.1594/EURORAD/CASE.8944
ISSN:	1563-4086