Bacillus cereus causing fulminant sepsis and hemolysis in two patients with acute leukemia

Purpose: Hemolysis is so rarely associated with Bacillus cereus sepsis that only two very well documented cases have been reported. This article repor ts two unusual cases of Bacillus cereus sepsis with massive intravascular h emolysis in patients who had acute lymphoblastic leukemia (ALL). Patients and Methods: A 20-year-old woman who was 9 weeks pregnant experien ced a relapse of ALL. A therapeutic abortion was performed. During week 4 o f reinduction the patient had abdominal pain, nausea, and vomiting, with se vere neutropenia but no fever. Her condition deteriorated rapidly with card iovascular collapse, acute massive intravascular hemolysis, and death withi n hours of the onset of symptoms. Blood cultures were positive for Bacillus cereus. Postmortem histologic examination and cultures revealed Bacillus c ereus and Candida albicans in multiple organs. The second patient, a 10-yea r-old girl, presented with relapsed T-cell ALL. In the second week of reind uction, she had abdominal pain followed by hypotension. Again, no fever was noted. Laboratory studies showed intravascular hemolysis 12 hours after ad mission. Aggressive support was promptly initiated. Despite disseminated in travascular coagulation; cardiovascular, hepatic, and renal failure; and mu ltiple intracerebral hypodense lesions believed to be infarcts, the patient recovered fully and resumed reinduction therapy. Conclusions: Bacillus cereus infection can have a fulminant clinical course that may be complicated by massive intravascular hemolysis. This pathogen should be suspected in immunosuppressed patients who experience gastrointes tinal symptoms and should not be precluded by the absence of fever, especia lly if steroids such as dexamethasone are being given. Exchange transfusion may be lifesaving in Bacillus cereus septicemia associated with massive he molysis.