Introduction: There is currently no consensus on management of appendicitis in neutropenic and platelet refractory patients. Case Presentation: A 30 year-old female with high-risk acute monoblastic leukemia with 11q23 translocation undergoing Cytarabine and Adriamycin induction therapy (day number 18) experienced acute right lower quadrant abdominal pain. Hospital course had been complicated by persistent neutropenic fevers despite broad-spectrum antibiotics, and transfusion refractory thrombocytopenia. The patient's platelet count was 1 x 10ˆ3 on the particular morning. She was status-post IVIG and dexamethasone and had been receiving platelet transfusions daily with only minimal increases in her platelet count (maximal response of 3,000). No cross-matched or HLA matched platelets were available at the time. A stat CT abdomen/pelvis showed findings consistent with early appendicitis but no perforation. She also had gingival bleeding and had been passing blood clots per rectum. Given her high risk of bleeding, and lack of ability to raise her critical thrombocytopenia, decision was made to treat the patient medically, adding metronidazole to the meropenem she had been receiving. Abdominal exams were monitored serially with potential need for emergent surgery should her clinical status deteriorate. Her pain resolved the following morning with repeat CT abdomen/pelvis a month later showing resolution of the inflammation at the appendix. Discussion: This patient presented with a therapeutic dilemma. The conventional wisdom is to treat patients with appendicitis surgically, given the high mortality rate should an appendix perforation occur. Currently there is no consensus on the optimal treatment of appendicitis should it arise in the setting of treatment for leukemia. The added complexity of thrombocytopenia prompted conservative therapy. It remains unclear whether the dexamethasone that was administered for the patient's thrombocytopenia helped control the pain and inflammation of the appendicitis, as the patient's symptoms had largely resolved by the following morning. To our knowledge, there are no published case reports on conservative treatment of appendicitis in someone with refractory thrombocytopenia and neutropenia.Figure 1