Haematologica 2002; 87:(12)ECR39
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Fingertip cellulitis after fingerstick for capillary microhematocrit measurement in a patient with chronic lymphocytic leukemia: an uncommon infectious complication.
Eduardo Arellano-Rodrigo, Montserrat Rovira*, María Teresa Cibeira, Deborah Abelló, Emili Montserrat
Institute of Hematology and Oncology, Postgraduate School of Hematology Farreras-Valentí and *BMT Unit Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona.
Correspondence: Dr. Eduardo Arellano-Rodrigo, MD, Institute of Hematology and Oncology, Postgraduate School of Hematology Farreras-Valentí, Hospital Clínic, Villarroel, 170, Barcelona 08036, Spain. Phone: international +34.93.2275414. Fax: international +34.93.2275783. E-mail:34004ear@comb.es

We describe the case of a 48 year-old woman with heavily pretreated and advanced chronic lymphocytic leukemia who developed a life-threatening fingertip cellulitis by Staphylococcus aureus occurring as a complication of fingerstick for microhematocrit measurement, a previously unreported infectious complication. The patient was successfully treated with prompt surgery and broad-spectrum antibiotics.
Infectious complications are the major cause of morbidity and mortality in advanced chronic lymphocytic leukemia (CLL) despite improvement in therapeutic and supportive approaches to this leukemia.1,4 The majority of infections in patients with CLL are generally due to encapsulated bacteria and respiratory tract, urinary tract and skin are the most susceptible infection sites. Ref. 1,2,5 The use of fludarabine in the treatment of CLL is associated with opportunistic infections.5,6
The suceptibility of patients to infection is related to their degree of hypogammaglobulinemia, neutropenia, monocytopenia, advanced Rai stage, previous chemotherapy or immunosuppressive regimens in cases of autoimmune cytopenia.1,2,5,6-7
In practical hematology, the rapid obtainment of capillary hematocrit in hematologic patients receiving palliative treatment is important in the management of anemia and blood transfusion requirements. We describe here the case of a patient with advanced CLL who developed a fingertip celullitis by Staphylococcus aureus after capillary microhematocrit, a previously unreported infectious complication.
A 48 year-old woman was diagnosed with B-CLL in May 1995. She was previously treated with chlorambucil plus prednisone, FCM (fludarabine, cyclophosphamide and mitoxantrone) and an autologous peripheral blood stem-cell transplantation that resulted in a complete molecular response. She presented again in January 2001 with progressive lymphadenopathy and received alemtuzumab (Campath-1H) with partial remission. Currently, she has a Rai stage IV and is now receiving palliative treatment with monthly cyclophosphamide and prednisone.
On an outpatient basis, a fingertip was lanced after antisepsis of the skin with alcohol and capillary blood was collected for microhematocrit measurement without immediate complications. Four days after fingerstick, the patient developed fever, and the fingertip of her third finger on the right hand gradually became tender, painless, swollen and erythematous. On examination, the distal portion of the middle finger was edematous, markedly warm and erythematous with a small subcutaneous black necrotic area. Plain radiograhs showed no evidence of osteomyelitis. The white blood cell count was 2.4x109/L with 95 % lymphocytes and 5 % neutrophils, hemoglobin 90 g/L, and the platelet count 552.4x109/L. The CD4+ lymphocyte count was 0.2 2.4x109/L with severe hypogammaglobulinemia. Routine biochemical tests were within normal ranges.
Thus, the patient underwent surgery for incision and drainage of the distal portion of third finger under a digital block. Intravenous piperacillin tazobactam and vancomycin were administered empirically. Filgrastim was given for 6 days. Blood cultures were negative, but sterile cultures obtained during surgery were positive for S. aureus sensitive to methicillin. The patient became free of symptoms a few days after treatment was started and was discharged in a good condition.
In a recent study, the frequency of serious bacterial cellulitis was 2.3 % in patients with fludarabine-refractory CLL. Ref. 8 However, the incidence of skin and soft tissue infections in patients with CLL classified as severe or moderate in other studies are higher.1,2,5 Upper extremity infections in immunocompromised hosts can rapidly progress to tissue destruction, necrosis and sepsis. The patient herein referred had a life-threatening fingertip cellulitis occuring as a complication of fingerstick for microhematocrit measurement that was successful treated with surgery and broad-spectrum antibiotics. It is conceivable that cellulitis may have been caused by methicillin-sensitive S. aureus as indigenous flora colonizing the patients skin, and that pricking the skin for blood microhematocrit monitoring provided a port of entry.
We report this case because of the rarity of this infectious complication in advanced CLL. Although finger cellulitis after fingerstick is relatively rare, finger infections have been described in patients with insulin-dependent diabetes mellitus because of chronic microtrauma to the skin associated with self-monitoring of capillary blood glucose.9-10
The heavy immunosupression due to advanced CLL and different treatment approaches utilized play a major role in susceptibility to infection of this case report.1,2,5,6,8 Venopuncture should be considered as a safé technique for blood collection than repeated capillary fingerstick in patients with advanced CLL.
In conclusion, although infrequent, digital cellulitis after fingerstick is a severe infection that hematologists must keep in mind, and should include in the differencial diagnosis of infectious complications in patients with advanced CLL. We advocate rapid surgical treatment and early institution of intravenous antibiotics.

References

  1. Montserrat-Costa E, Matutes E, Rozman C, Feliu E, Grañena A, Hernández-Nieto L, et al. Infecciones en la leucemia linfoide crónica. Sangre 1977;22:968-75.
  2. Molica S, Levato D, Levato L. Infections in chronic lymphocytic leukemia. Analysis of incidence as a function of length of follow-up. Haematologica 1993;78:374-7.
  3. Molica S, Musto P, Chiurazzi F, Specchia G, Brugiatelli M, Cicoira L, et al. Prophylaxis against infections with low-dose intravenous immunoglobulins (IVIG) in chronic lymphocytic leukemia. Results of a crossover study. Haematologica 1996;81:121-6.
  4. Montillo M, Cafro AM, Tedeschi A, Brando B, Oreste P, Veronese S, et al. Safety and efficacy of subcutaneous Campath-1H for treating residual disease in patients with chronic lymphocytic leukemia responding to fludarabine. Haematologica 2002;87:695-700.
  5. Molica S. Infections in chronic lymphocytic leukemia: risk factors and impact on survival and treatment. Leuk Lymphoma 1994;13:203-14.
  6. Anaissie EJ, Kontoyiannis DP, O´Brien S, Kantarjian H, Robertson L, Lerner S, et al. Infections in patients with chronic lymphocytic leukemia treated with fludarabine. Ann Intern Med 1988;129:559-66.
  7. Rozman C, Montserrat E, Viñolas N. Serum immunoglobulins in B-chronic lymphocytic leukemia. Natural history and prognostic significance. Cancer 1988;61:279-83.
  8. Perkins JG, Flynn JM, Howard RS, Byrd JC. Frequency and type of serious infections in fludarabine-refractory B-cell chronic lymphocytic leukemia and small lymphocytic lymphoma. Implications for clinical trials in this patient population. Cancer 2002;94:2033-9.
  9. Newfield RS, Vargas I, Huma Z. Eikenella corrodens infections: case report in two adolescent females with IDDM. Diabetes Care 1996;19:1011-3.
  10. Gonzalez MH, Bochar S, Novotny J, Brown A, Weinzweig N, Prieto J. Upper extremity infections in patients with diabetes mellitus. J Hand Surg 1999;24A:682-6.