EP311 - Necrotic Anal Fissure and Perineal Sepsis as a Result of Acute Neutropenia in an Otherwise Healthy Patient

Purpose/Background: The patient is a 47-year-old male with a history of hypertension who presented with a week of fevers up to 103, perirectal pain, and bright red blood per rectum. He was recently treated prior to presentation with amoxicillin for oral infection. Due to the oral pain, he developed dehydration and severe constipation. He had a hard bowel movement and had been having perianal pain ever since. On presentation, he was found to be severely neutropenic and had Enterobacter cloacae bacteremia. He was admitted to the hospital and placed on Ertapenem. He had no apparent cause for his neutropenia; all viral work-up was negative. CT imaging revealed no obvious perirectal abscess, but exam was concerning for a large posterior ulceration with skin necrosis and erythema. Heme/onc was consulted for input on his neutropenia. Over the course of a few hours he had continued pain, tachycardia, and spreading erythema with concern for perineal sepsis, so he was taken to the operating room urgently.

Methods/Interventions: The patient underwent an exam under anesthesia. He was found to have a necrotic posterior midline fissure with necrosis of superficial perianal skin posteriorly bilaterally. He underwent fissurectomy and debridement of perianal superficial soft tissue (3x2cm on each side).

Results/Outcomes: The patient had persistent neutropenic fevers postoperatively although the debridement site remained healthy. Heme/onc started him on Granix POD 5. His absolute neutrophil count recovered within three days. His white blood cell count did spike to 50,000 but slowly started to return to normal range. He continued to improve and was discharged home on POD 10 with Linezolid for 4 more days. On follow-up with heme/onc it was determined his acute neutropenia was due to immune-mediated destruction possibly due to oral infection vs. amoxicillin use as it had recovered and maintained after Granix administration. He followed up in office 1 week later with good healing of his wounds and normal labs. On office visit 2 months postoperatively, he showed almost complete resolution of the wounds and anal fissure.

Conclusion/Discussion: Perianal and rectal complications are common in patients with chemotherapy induced neutropenia. Although this patient had never received chemotherapy and was otherwise young and healthy, his agranulocytosis made him prone to infection with fecal flora. Vigilance needs to remain high in patients with neutropenia presenting with anorectal symptoms as delay in treatment can be devastating.

Fig 1.
Intraoperative picture of necrotic fissure
Fig 2.
Postoperative day 9 after debridement and fissurectomy