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Case Reports
. 2018 Mar 8;13(3):568-572.
doi: 10.1016/j.radcr.2018.02.017. eCollection 2018 Jun.

Perforated jejunitis in a child with acute lymphoblastic leukemia treated with pegaspargase

Elizabeth R Tang  1 , Teresa Chapman  1 , Laura S Finn  2 , Kasey J Leger  3
Affiliations
Case Reports

Perforated jejunitis in a child with acute lymphoblastic leukemia treated with pegaspargase

Elizabeth R Tang et al. Radiol Case Rep. .

Abstract

Survival rates of children with acute lymphoblastic leukemia have improved since the incorporation of asparaginase in the treatment protocol, but the medication has potential serious complications, including vascular thrombosis. Here, we describe the case of a 13-year-old boy with pre-T-cell acute lymphoblastic leukemia whose treatment course was complicated by perforated jejunitis requiring resection of a portion of his small bowel. Pathologic assessment showed transmural ischemia, mesenteric venous and arterial thrombi, and scattered cytomegalovirus inclusion bodies. Pediatric mesenteric ischemia is rare, and its consideration in patients treated with asparaginase is discussed.

Keywords: Acute lymphoblastic leukemia; Acute mesenteric ischemia; Asparaginase; Complications; Computed tomography; Pediatric.

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Figures

Fig. 1
Fig. 1
Abdominal imaging acquired on day 14 of induction chemotherapy after onset of abdominal pain showing jejunal pneumatosis and dissection of gas through the mesentery into the retroperitoneum and the portal venous system. (A) The upright anterior-posterior abdominal radiograph shows pneumatosis in the left upper quadrant (white arrows), as well as air-fluid levels in mildly dilated loops of bowel (white arrowheads). Contrast-enhanced computed tomography images in (B) the coronal plane with soft tissue algorithm and in (C) the axial plane with lung algorithm shows pneumatosis involving an abnormally dilated segment of jejunum (white arrows in B) and abnormally enhancing mucosa in the jejunum (white arrowheads in B). Abnormal retroperitoneal air is present at the diaphragmatic hiatus (black arrows in C), and portal venous gas is also observed (black arrow in B, black arrowheads in C).
Fig. 2
Fig. 2
Cytomegalovirus inclusions (arrowheads) were identified in the endothelial cells of the mucosa (A) and in the submucosal stromal cells (B) (hematoxylin and eosin, 200×). Mesenteric arteries (C, D, left) have fibrin thrombi at varying stages of organization, adherent to the walls, and are variably occluding the lumens. A strand of fibrin clings to the vein wall (C, right). Fibrin and red and white blood cells obstruct a mesenteric vein (D, right) (hematoxylin and eosin, 100×). Low-power images show a small segment of residual mucosa adjacent to an ulcer bed (arrow) that is covered by bile-stained fibrinous exudate, resembling a pseudomembrane (E). There is partial necrosis of the muscularis propria (*) and a fibrotic serosa that contains dilated lymphatic spaces (E). Diffuse ulceration is associated with full-thickness necrosis (*, F) (Masson trichrome, 40×).
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