J Hematol

Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Hematol and Elmer Press Inc

Journal website https://www.thejh.org

Review

Volume 13, Number 1-2, April 2024, pages 1-11

Anorectal Infections in Neutropenic Leukemia Patients: A Common Clinical Challenge

**Table 1.** Differential Diagnosis of Non-Healing Perianal Lesions in Cytopenic Patients With Leukemia [28, 45]
Sexually transmitted diseases (human papilloma virus, herpes simplex virus, syphilis, chlamydia, gonorrhea, Hemophilus ducreyi)
Cytomegalovirus proctitis
Histoplasma infection of the anus
Anal tuberculosis
Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)
Pyoderma gangrenosum
Complications post radiation therapy for extramedullary focal disease
Side effects of medication (e.g., bevacizumab, imiquimod, nicorandil)
Malignancies (leukemia deposits in the anorectal area, anal cancer)
Autoimmune disorders (systemic lupus erythematosus, Behcet’s disease, sarcoidosis)
Dermatological conditions (e.g., psoriasis, Lichen sclerosus)

Table 1. Differential Diagnosis of Non-Healing Perianal Lesions in Cytopenic Patients With Leukemia [28, 45]

Sexually transmitted diseases (human papilloma virus, herpes simplex virus, syphilis, chlamydia, gonorrhea, Hemophilus ducreyi)

Cytomegalovirus proctitis

Histoplasma infection of the anus

Anal tuberculosis

Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)

Pyoderma gangrenosum

Complications post radiation therapy for extramedullary focal disease

Side effects of medication (e.g., bevacizumab, imiquimod, nicorandil)

Malignancies (leukemia deposits in the anorectal area, anal cancer)

Autoimmune disorders (systemic lupus erythematosus, Behcet’s disease, sarcoidosis)

Dermatological conditions (e.g., psoriasis, Lichen sclerosus)

**Table 2.** Summary of Representative Studies of Medical Management With or Without Surgical Approach in Anorectal Infections in Cancer Patients
Authors	Study type	Year	Number of patients	Type of cancer	Therapeutic approach	Resolution (n)	Later recurrence (n)
Barnes et al [25]	Retrospective	1984	16	Mixed acute leukemias	Surgical n = 10	10	0
					Spontaneous drainage n = 5	5	0
Boddie et al [31]	Retrospective	1986	54 (different anorectal pathologies)	Leukemia	Surgical n = 11	N/A	4
					Conservative management n = 25	N/A	N/A
Glenn et al [46]	Retrospective	1988	44	Solid and hematological malignancies	Surgical n = 26	11	4
					Conservative management n = 18	14	9
Carlson et al [47]	Retrospective	1988	20	Leukemia	Surgical n = 9	6	3
					Conservative management n = 11	11	0
Grewal et al [48]	Retrospective	1994	81 (different anorectal pathologies	Leukemia	Surgical n = 29	N/A	N/A
					Conservative management n = 54	N/A	N/A
North et al [16]	Retrospective	1996	25	Acute and chronic leukemias	Surgical n = 13	13	0
					Conservative management n = 12	7	5
Buyukasik et al [21]	Retrospective	1998	20	Acute and chronic leukemias	Surgical n = 10	9	1
					Conservative management n = 10	3	7
Lehrnbecher et al [22]	Retrospective	2002	64	Solid and hematological malignancies	Surgical n = 25	18	7
					Conservative management n = 39	N/A	N/A
Badgewell et al [11]	Retrospective	2009	100	Solid and hematological malignancies	Surgical n = 58	N/A	N/A
					Conservative management n = 42	N/A	N/A
Morcos et al [10]	Retrospective	2013	13	Solid and hematological malignancies	Surgical n = 13	13	N/A
Loureiro et al [24]	Retrospective	2018	27	Mixed hematological malignancies	Surgical n = 15	14	1
					Conservative management n = 12	9	2

Table 2. Summary of Representative Studies of Medical Management With or Without Surgical Approach in Anorectal Infections in Cancer Patients

Authors

Study type

Year

Number of patients

Type of cancer

Therapeutic approach

Resolution (n)

Later recurrence (n)

Barnes et al [25]

Retrospective

1984

Mixed acute leukemias

Surgical n = 10

Spontaneous drainage n = 5

Boddie et al [31]

Retrospective

1986

54 (different anorectal pathologies)

Leukemia

Surgical n = 11

N/A

Conservative management n = 25

N/A

Glenn et al [46]

Retrospective

1988

Solid and hematological malignancies

Surgical n = 26

Conservative management n = 18

Carlson et al [47]

Retrospective

1988

Leukemia

Surgical n = 9

Conservative management n = 11

Grewal et al [48]

Retrospective

1994

81 (different anorectal pathologies

Leukemia

Surgical n = 29

N/A

Conservative management n = 54

N/A

North et al [16]

Retrospective

1996

Acute and chronic leukemias

Surgical n = 13

Conservative management n = 12

Buyukasik et al [21]

Retrospective

1998

Acute and chronic leukemias

Surgical n = 10

Conservative management n = 10

Lehrnbecher et al [22]

Retrospective

2002

Solid and hematological malignancies

Surgical n = 25

Conservative management n = 39

N/A

Badgewell et al [11]

Retrospective

2009

100

Solid and hematological malignancies

Surgical n = 58

N/A

Conservative management n = 42

N/A

Morcos et al [10]

Retrospective

2013

Solid and hematological malignancies

Surgical n = 13

N/A

Loureiro et al [24]

Retrospective

2018

Mixed hematological malignancies

Surgical n = 15

Conservative management n = 12

**Table 3.** Ongoing Questions Regarding Risk Factors and Management of Anorectal Infections in Neutropenic Patients With Leukemia
CT: computed tomography; G-CSF: granulocyte colony-stimulating factor; MDR: multidrug resistant; WBC: white blood cell.
Risk factors
Composition of the microbiome
Impact of comorbidities (e.g., diabetes mellitus)
Influence of prior gastrointestinal infections
Type and sequence of chemotherapy
Modulating effect of antibacterial and antifungal prophylaxis to the presentation, severity and pathogens associated with anorectal infections
Management
Is there a predictive value of rectal swabs?
Optimal empiric choice and duration of anti-infective therapy
Time to transition from intravenous to oral antibiotics
Best strategies for source control (incision and drainage vs. percutaneous drainage) and ideal timing
Indication and timing for granulocyte transfusion
Pain management, effective use of non-narcotics
Prevention
How to modify anti-infective prophylaxis to reduce the recurrence rate of perianal infections?
Is there a role of surgical management of anal fissures, thrombosed hemorrhoids prior to next chemotherapy?
Timing of restarting subsequent chemotherapy? Is a repeat CT scan of the abdomen/pelvis indicated to assess this?
Is there a need to modify chemotherapy in a patient with recent severe anorectal infection?
Is there are role of G-CSF as prophylaxis?
Is there a role for WBC transfusions in selected patients (severe episodes, isolation of an MDR pathogen) to prevent relapse?

Table 3. Ongoing Questions Regarding Risk Factors and Management of Anorectal Infections in Neutropenic Patients With Leukemia

CT: computed tomography; G-CSF: granulocyte colony-stimulating factor; MDR: multidrug resistant; WBC: white blood cell.

Risk factors

Composition of the microbiome

Impact of comorbidities (e.g., diabetes mellitus)

Influence of prior gastrointestinal infections

Type and sequence of chemotherapy

Modulating effect of antibacterial and antifungal prophylaxis to the presentation, severity and pathogens associated with anorectal infections

Management

Is there a predictive value of rectal swabs?

Optimal empiric choice and duration of anti-infective therapy

Time to transition from intravenous to oral antibiotics

Best strategies for source control (incision and drainage vs. percutaneous drainage) and ideal timing

Indication and timing for granulocyte transfusion

Pain management, effective use of non-narcotics

Prevention

How to modify anti-infective prophylaxis to reduce the recurrence rate of perianal infections?

Is there a role of surgical management of anal fissures, thrombosed hemorrhoids prior to next chemotherapy?

Timing of restarting subsequent chemotherapy? Is a repeat CT scan of the abdomen/pelvis indicated to assess this?

Is there a need to modify chemotherapy in a patient with recent severe anorectal infection?

Is there are role of G-CSF as prophylaxis?

Is there a role for WBC transfusions in selected patients (severe episodes, isolation of an MDR pathogen) to prevent relapse?