Acute Myeloid Leukemia Presenting as Acute Appendicitis

Appendicitis in leukemic patients is uncommon but associated with increased mortality. Additionally, leukemic cell infiltration of the appendix is extremely rare. While appendectomy is the treatment of choice for these patients, diagnosis and management of leukemia have a greater impact on remission and survival. A 59-year-old Caucasian female was admitted to the surgical service with acute right lower quadrant pain, nausea, and anorexia. She was noted to have leukocytosis, anemia, and thrombocytopenia. Abdominal imaging demonstrated appendicitis with retroperitoneal and mesenteric lymphadenopathy for which she underwent laparoscopic appendectomy. Peripheral smear, bone marrow biopsy, and surgical pathology of the appendix demonstrated acute myeloid leukemia (AML) with nonsuppurative appendicitis. In the setting of AML, prior cases described the development of appendicitis with active chemotherapy. Of these cases, less than ten patients had leukemic infiltration of the appendix, leading to leukostasis and nonsuppurative appendicitis. Acute appendicitis with leukemic infiltration as the initial manifestation of AML has only been described in two other cases in the literature with an average associated morbidity of 32.6 days. The prompt management in this case of appendicitis and AML resulted in an overall survival of 185 days. 1. Introduction Early and prompt diagnosis of AML has been proven to decrease morbidity and mortality [1]. Acute appendicitis has infrequently been described in the setting of known acute leukemia and is generally associated with patients receiving active chemotherapy [2]. Leukemic cell infiltration of the appendix, first reported by Rappaport in 1967, is even less-well described [3]. Despite the infrequent occurrence, appendicitis in leukemic patients is associated with a higher mortality rate [2, 4]. While appendectomy is accepted as the treatment of choice for appendicitis in patients with acute leukemia [5], diagnosis and prompt management of the leukemia have a greater impact on achieving a complete remission and, thus, overall survival. This case of acute appendicitis demonstrates the importance of maintaining a broad differential and seeking prompt diagnostic consultation. 2. Case Presentation A 59-year-old Caucasian female, with no significant past medical history, presented to the surgical service for management of acute appendicitis. The patient described two days of lower abdominal pain that she noted to be worse on the right with sudden onset and increasing severity. She noted associated diarrhea two days prior to