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Case Report Pneumoperitoneum Without Peritonitis After Allogeneic Peripheral Blood Stem Cell Transplantation

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Case Report Pneumoperitoneum Without Peritonitis After Allogeneic Peripheral Blood Stem Cell Transplantation Bone Marrow Transplantation, (1998) 21, 1153–1154 1998 Stockton Press All rights reserved 0268–3369/98 $12.00 http://www.stockton-press.co.uk/bmt Case report Pneumoperitoneum without peritonitis after allogeneic peripheral blood stem cell transplantation M de Magalhaes-Silverman, J Simpson and E Ball Division of Hematology/Bone Marrow Transplantation, Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Summary: matosis (Figure 1). Six months later he continues well on 100 mg of azathioprine and prednisone (30 mg alternating Allogeneic blood stem cell transplantation is associated with 5 mg). with multiple complications. We report a case of pneu- moperitoneum without peritonitis associated with colonic pneumatosis in a patient who had undergone an allogeneic peripheral blood cell transplant Discussion Keywords: pneumoperitoneum; allogeneic; peripheral blood Spontaneous pneumoperitoneum is sometimes associated with pneumatosis intestinalis, traumatic pneumothorax, and chronic obstructive lung disease.1,2 In our patient it was most likely related to pneumatosis intestinalis. We report a case of pneumoperitoneum without peritonitis associated with colonic pneumatosis in a patient who received an allogeneic blood cell transplant. The patient is a 27-year-old male with T cell-rich B cell lymphoma stage IV treated with etoposide, doxorubicin, cyclophosphamide, vincristine, prednisone and bleomycin (VACOP-B) who achieved a complete response. In June of 1996 he relapsed in the bone marrow. He underwent ther- apy with one cycle of ifosfamide, cisplatinin and etoposide (ICE). He received busulfan at 16 mg/kg and cyclopho- phamide at 120 mg/kg (BUCY2) followed by blood stem cells from his HLA-identical sister. Graft-versus-host dis- ease (GVHD) prophylaxis was tracolimus. Neutrophils engrafted at day 12 post transplant and platelets at day 22. The patient developed clinical grade II acute GVHD (skin and gut) which was treated with steroids. Acute GVHD progressed to chronic GVHD affecting skin, conjunctiva, liver and gut, which eventually improved with the addition of azathioprine. Sixteen months later, on a routine radiol- ogic examination the patient was found to have a large amount of air around the ascending colon. He was asympto- matic and physical examination was unrevealing. Labora- tory tests showed normal liver function, amylase and lipase. Follow-up within a month continued to show a large amount of air surrounding the ascending colon and proxi- mal transverse colon with possible associated colonic pneu- Correspondence: Dr M de Magalhaes-Silverman, Division of Hematology/Oncology, University of Iowa Hospitals & Clinics, 200 Figure 1 Abdominal roentgenogram showing a large amount of air sur- Hawkins Drive, Iowa City, IA 52242, USA rounding the ascending colon and proximal transverse colon with associa- Received 19 January 1998; accepted 23 January 1998 ted pneumatosis. Pneumoperitoneum without peritonitis after PBSCT M de Magalhaes-Silverman et al 1154 Pneumatosis intestinalis is a rare condition characterized References by the radiologic or pathologic demonstration of air within 3 1 Gant CB, Daniel WW, Halenbeck GA. Nonsurgical pneumo- the bowel wall. The etiology of this disorder is unknown peritoneum. Am J Surg 1977; 12: 208–211. but it has been associated with congenital disorders, 2 Gutkin Z, Iellin A, Meged S et al. Spontaneous pneumoperi- collagen vascular diseases, acquired immunodeficiency, toneum without peritonitis. Int Surg 1992; 77: 219–222. infection, and endoscopic procedures.4 3 Sweriduk ST, DeLuca SA. Pneumatosis cystoides intestinalis. Pieterse and coworkers,5 in a review of nine patients who Am Fam Physician 1985; 32: 113–114. underwent colon resections for pneumatosis intestinalis, 4 Samach M, Brandt LJ, Bernstein LH. Spontaneous pneumo- demonstrated mucosal abnormalities in most specimens and peritoneum with pneumatosis cystoides intestinalis in a patient concluded that the air entered from the mucosal surface. with muxed connective tissue disease. Am J Gastroenterol 1978; 69: 494–500. They recorded mucosal changes similar to those found in 5 Pieterse AS, Leong ASY, Rowland R. The mucosal changes chronic inflammatory bowel disease and GVHD ranging and pathogenesis of pneumatosis cystoides intestinalis. Hum from cryptitis, cryptic abscesses, and sequential crypt dila- Pathol 1985; 16: 683–688. tation and rupture, which provide a mechanism of air entry 6 Lipton J, Patterson B, Mustard R et al. Pneumatosis intesti- into the subserosal air sacs, which can rupture into the per- nalis with free air mimicking intestinal perforation in a bone itoneum. It has been previously been reported in association marrow transplant patient. Bone Marrow Transplant 1994; 14: with bone marrow transplantation.6–8 Seven of 26 reported 323–326. cases were detected only radiographically. 7 Navari RM, Sharma P, Deeg HL. Pneumatosis cystoided intestinalis following allogeneic marrow transplantation. Pneumoperitoneum is one of the complications of pneu- Transplant Proc 1983; 25: 1720–1724. matosis intestinalis and in most cases has a benign course. 8 Hall RR, Anagnastou A, Kanojia M et al. Pneumatosis intesti- We feel that in the absence of signs of peritonitis patients nalis associated with graft versus host disease. Transplant with such a presentation can be managed conservatively. Proc 1984; 26: 1666–1668..
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