2. Case Presentation
A 10-year-old, 34 kg female with no significant medical history was
admitted with recently diagnosed acute myeloid leukemia. She was treated
with etoposide 150 mg/m2/dose on days 1-5, cytarabine
200 mg/m2/dose on days 6-12, mitoxantrone 5
mg/m2/dose on days 6-10, and triple intrathecal
therapy on day 6 as induction therapy (JPLSG AML-05
protocol2). Following chemotherapy, her course was
complicated by continued febrile neutropenia and oral mucositis. Broad
spectrum antibiotics including meropenem, teicoplanin, and caspofungin
with granulocyte colony-stimulating factor (G-CSF) was initiated. As
multiplex polymerase chain reaction proved positive for Herpes
simplex viral infection, acyclovir was added. She complained of severe
throat pain and dysphagia due to worsening mucositis and required
continuous infusion of morphine.
On day 24, the patient complained of increasing throat pain and
difficulty breathing. She was found sitting up in bed, leaning forward,
drooling. Pan-inspiratory stridor and mild effort of breathing was
observed on physical examination. She was alert with her vital signs
otherwise stable. Examination on nasolaryngoscopy revealed extensive
desquamation of the oropharyngeal mucosa and multiple, confluent
ulcerative lesions with significant edema extending down to the
arytenoid cartilage (Fig. 1). The patient was taken to the operating
room for elective intubation with otolaryngology team on standby for
tracheostomy placement. A size 5.0 mm internal diameter endotracheal
tube was successfully inserted by video laryngoscopy with anesthesia
maintaining spontaneous ventilation.
The patient was then transported to the pediatric intensive care unit.
As infection being considered as an aggravating factor, antimicrobiotic
agents and G-CSF was continued, and granulocyte transfusion from
paternal donor was attempted.
On day 28, she developed significant spontaneous bleeding from the
gingiva and the oropharyngeal ulcers, resulting in hemorrhagic shock.
Platelet transfusions and vasoconstrictors were warranted for
resuscitation. Nasolaryngoscopy revealed further aggravation of the
ulcerative lesions with active oozing and worsening edema of the
oropharyngeal tissues showing complete obstruction of the
retropharyngeal space. Packing of the oropharyngeal space was performed
as electrocoagulation of bleeding vessels failed to control bleeding.
Surgical tracheostomy was considered taking the above finding into
account. After thorough discussion with the oncologists and the
otolaryngologists a decision was made to wait for resolution of
neutropenia considering the elevated risk of procedure in the nadir
phase and expected improvement of mucositis following recovery of
neutrophil counts.
On day 29, absolute neutrophil count exceeded 500 /µL and G-CSF was
discontinued. Her bleeding was well controlled. On day 31, defervescence
was achieved. On day 32, improvement of the ulcerative lesions and
airway swelling was confirmed on nasolaryngoscopy. Adequate leakage
around the endotracheal tube was verified. The patient was able to
cough, swallow efficiently requiring minimum ventilatory support.
Extubation was successful on first attempt. Repeated blood cultures
obtained throughout her course were found to be negative. Her course
after extubation was uneventful.