Leukemic infiltration mimicking an infected anal fissure in primary refractory acute myeloid leukaemia: challenging the role of surgery in neutropenic patients

Abstract

The management of persistent anorectal disease in neutropenic patients with acute myeloid leukaemia (AML) remains controversial because operative intervention has traditionally been discouraged owing to concerns regarding bleeding, impaired wound healing, and septic complications. Although conservative management is recommended as the initial treatment strategy, the optimal approach for patients with persistent symptoms remains uncertain. We report the case of a 20-year-old woman with primary refractory AML who developed severe anorectal pain during prolonged febrile neutropenia despite broad-spectrum antimicrobial therapy and comprehensive conservative management. Pelvic magnetic resonance imaging demonstrated an active sinus tract without a drainable abscess. Following multidisciplinary assessment, examination under anaesthesia with fissurectomy was performed. Histopathological examination confirmed leukemic infiltration of the anal fissure, with blast cells positive for myeloperoxidase and CD68, establishing the definitive diagnosis. The patient experienced marked postoperative improvement in anorectal pain. This case supports an individualised multidisciplinary approach in which failure of optimised conservative management should prompt careful reassessment with appropriate imaging rather than automatic exclusion of surgery. In carefully selected patients, operative intervention may provide both definitive diagnosis and meaningful symptomatic benefit.