(622) Airway Emergency, Bicytopenia, and . . . Cancer? Unmasking a Hidden Malignancy

Introduction: Although B-cell acute lymphoblastic leukemia (B-ALL) is the most common malignancy in pediatrics, initial presentation with bicytopenia is not. Presenting with sepsis and epiglottitis with laboratory values concerning for marrow suppression, this case underscores the importance of maintaining a high index of suspicion for alternate diagnoses.

Description: A vaccinated 3-year-old male with history of iron deficiency anemia presented to the emergency department with fever, sore throat, and decreased oral intake. On exam, he was encephalopathic with poor perfusion and periorbital edema. CT head was negative for intracranial process but showed enlarged adenoids with an extensive effusion of deep neck and retropharyngeal space. Bedside flexible nasopharyngolaryngoscopy demonstrated an obstructed airway with enlarged adenoids, exudative tonsils, and epiglottic and arytenoid edema so he was intubated by ENT. Initial laboratory evaluation was notable for anemia, leukopenia, and normal platelets. Due to toxic appearance, patient was started on broad spectrum antibiotics to cover most common causes of epiglottitis and deep space neck infections. Blood culture revealed streptococcus pneumoniae bacteremia. Oncology, concerned that the patient’s bicytopenia may not be fully explained by infectious bone marrow suppression, performed a bone marrow biopsy which revealed a diagnosis of B-ALL. He was transferred to the oncology unit after extubation to complete his antibiotic course and initiate chemotherapy and discharged home following treatment. Unfortunately, he returned 15 days after discharge with fatal gastrointestinal and pulmonary hemorrhage and Streptococcus pyogenes bacteremia.

Discussion: We report a case of B-ALL presenting with bicytopenia, epiglottitis, and streptococcus pneumoniae sepsis. His severe illness and history of anemia initially suggested other causes for his bicytopenia, but this case underscores the importance of a broad differential.