Neutropenic Enterocolitis: Case report and literature review

Typhlitis, is also known as neutropenic enterocolitis, affects the cecum and distal ileum. It was frequently encountered in pediatric patients who were undergoing treatment for leukemia. Nonetheless, it can affect adult patients, regardless of the cause of the immunosuppression. We report the case of a 20-year-old patient who was receiving chemotherapy for Osteosarcoma, who had a 6-day history of nausea and vomiting, fever sensation, diarrhea, and diffuse abdominal pain. Physical examination was relevant for hemodynamic instability, a distended and tender abdomen predominantly in the right iliac fossa. The laboratory workup showed severe neutropenia, thrombocytopenia, and electrolyte disturbances. The image studies evidenced edema of the ascending colon and cecum. Treatment was started with vasopressor support, correction of electrolyte alterations, blood cell and platelet transfusion, G-CSF, hydration, broad spectrum antibiotic therapy, initially with adequate clinical and laboratory response. After a few days, he presented lower gastrointestinal bleeding which was treated by conservative management. In conclusion, typhlitis must be suspected in every patient developing neutropenia as a reaction to chemotherapy and who also presents gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and intense abdominal pain.

La tiflitis o también denominada enterocolitis neutropénica afecta el ciego e íleon distal. Fue descrita comúnmente en pacientes pediátricos sometidos a tratamiento para leucemia; sin embargo, puede afectar al paciente adulto independiente de la causa que origine la inmunosupresión. Presentamos el caso de un paciente de 20 años con antecedente de osteosarcoma, quien acude con tiempo de enfermedad de 6 días caracterizado por náuseas y vómitos, sensación de alza térmica, diarrea y dolor abdominal difuso. Al examen físico se encuentra hemodinámicamente inestable, abdomen distendido y se corrobora el dolor abdominal a predominio en fosa iliaca derecha. Los exámenes de laboratorio mostraron neutropenia severa, trombocitopenia y alteraciones hidroelectrolíticas. En los estudios de imágenes la TC evidenció edema de asas delgadas, así como edema de pared del colon ascendente y ciego. Se inició tratamiento con soporte vasopresor, corrección de alteraciones hidroelectrolíticas, transfusión de paquetes globulares y plaquetas, G-CSF, hidratación, terapia antibiótica de amplio espectro, inicialmente con adecuada respuesta clínica y laboratorial. Al cabo de unos días presentó hemorragia digestiva baja como complicación que fue tratada mediante manejo conservador. En conclusión, la tiflitis debe sospecharse en todo paciente que desarrolla neutropenia luego de quimioterapia y que presenta síntomas gastrointestinales como náuseas, vómitos, diarrea y dolor abdominal intenso. El manejo conservador, en pacientes con hemorragia digestiva y tiflitis, que involucra corrección de coagulopatía, transfusión de paquetes globulares e hidratación, puede ser el adecuado en pacientes que no cursan con inestabilidad hemodinámica y logran controlar el sangrado.

Fatal Neutropenic Enterocolitis during Pegylated Interferon and Ribavirin Combination Therapy for Chronic Hepatitis C Virus Infection

It is known that neutropenia caused by combination pegylated interferon plus ribavirin therapy for hepatitis C virus (HCV) infection is well tolerated and carries a negligible risk of infection. Neutropenic enterocolitis is encountered most frequently in patients with hemato-oncologic diseases who are undergoing intensive chemotherapy. However, little information exists regarding this life-threatening event in the setting of HCV therapy. We present here an unusual case of fatal neutropenic enterocolitis in a cirrhotic patient receiving combination therapy for HCV infection. This is the first report of a death from neutropenic enterocolitis associated with treatment for chronic HCV infection. The present case suggests that caution should be exercised when continuing HCV therapy in neutropenic patients with advanced fibrosis, and the decision to maintain such therapy should be balanced against the potential for serious adverse events.

Neutropenic Enterocolitis after Chemotherapy for Colon Cancer

Neutropenic enterocolitis is observed in approximately 10~46% of patients with acute leukemia, as well as in patients with other diseases, like acquired immunodeficiency syndrom (AIDS), that lead to profound neutropenia. Patients who become neutropenic after combined chemotherapy are at special risk of developing neutropenic enterocolitis. With the recently increasing numbers of patients with solid tumors treated with high-dose chemotherapy, the frequency of this disease is expected to increase. However, this disease has been rarely reported in patients with colon cancer treated with leucovorin and 5-fluorouracil for adjuvant chemotherapy. We report a case of neutropenic enterocolitis after a treatment of 5-fluorouracil and leucovorin for sigmoid colon cancer.

Neutropenic Enterocolitis in Acute Myelogenous Leukemia

Neutropenic enterocolitis is an acute life-threatening, necrotizing inflammation of cecum and terminal ileum often seen in leukemia and lymphoma during periods of prolonged or severe neutropenia. It has been also referred to as necrotizing enterocolitis, ileocecal syndrome, or typhlitis (from the Greek word typhlon meaning cecum). The pathophysiology of the neutropenic enterocolitis is unknown but is believed to be multifactorial. The clinical symptoms of neutropenic enterocolitis are nonspecific including fever, abdominal pain (often right lower quadrant), abdominal distension, diarrhea, bloody stools, nausea, and vomiting. So acute appendicitis is should be included in the differential diagnosis. The early signs and symptoms are nonspecific and it may rapidly lead to intestinal perforation. The definite management of neutropenic enterocolitis is contrversial. but the prognosis is likely to be good with early diagnosis and proper management. We report one case of neutropenic enterocolitis in acute myelogenous leukemia with literature review.

Neutropenic Enterocolitis with Liver Abscess in a Young Patient with Leukemia after Chemotherapy

Neutropenic enterocolitis is a serious complication of chemotherapy for malignancies such as acute leukemia or lymphoma. The acute inflammatory disease may involve the terminal ileum, cecum and ascending colon. Although conservative care is recommended as the primary treatment modality, surgical intervention is essential for intestinal perforations, abscesses, or bleeding. We experienced a case of neutropenic enterocolitis with a liver abscess in a young leukemia patient. A 13-year-old boy with acute myelogenous leukemia had completed two cycles of chemotherapy (Arabinoside 300 mg, Dactinomycin 40 mg, VP-16 150 mg, 6- mercaptopurin 60 mg, dexametasone 3 mg). Ten days after completing the second cycle he had abdominal pain, low abdominal tenderness and a high fever. The WBC count in the peripheral blood was 210 cell/mm3. A CT scan demonstrated wall thickening of the terminal ileum and ascending colon, as well as 5 cm, and 6 cm sized homogeneous low-density areas in both hepatic lobes. A presumptive diagnosis was neutropenic enterocolitis with a liver abscess. The patient was managed conservatively with fluid resuscitation, a bowel rest, and broad-spectrum antibiotics. Twenty-five days later his abdominal pain was abruptly aggravated. The CT scan and Chest X-ray demonstrated free air in the peritoneal cavity. An emergency laparotomy was performed under a diagnosis of peritonitis with an intestinal perforation. The laparotomy show that, there were perforations at the pylorus of the stomach, and full thickness necrosis at multiple segments of the small bowel. Primary closure of the stomach, a segmental resection and an end-to-end anastomosis of the small bowel, and ileostomy were performed. However, postoperative leakage developed at the stomach. The patient recovered with supportive management. The patient had a third chemotherapy series 3 months after surgery. Three days after completing the third cycle, the patient developed peritonitis. A pyloric re-perforation of the stomach was observed on the laparotomy. Postoperative leakage developed after the primary closure of the stomach. The patient died of sepsis 54 days later. Therefore, intensive monitoring and close collaboration between the hematologist and the surgeon is essential for patients with neutropenic enterocolitis. Postoperative complications are quite common and can be fatal in patients with neutropenic enterocolitis that develops after chemotherapy.

Neutropenic Enterocolitis with Liver Abscess in a Young Patient with Leukemia after Chemotherapy

Neutropenic enterocolitis is a serious complication of chemotherapy for malignancies such as acute leukemia or lymphoma. The acute inflammatory disease may involve the terminal ileum, cecum and ascending colon. Although conservative care is recommended as the primary treatment modality, surgical intervention is essential for intestinal perforations, abscesses, or bleeding. We experienced a case of neutropenic enterocolitis with a liver abscess in a young leukemia patient. A 13-year-old boy with acute myelogenous leukemia had completed two cycles of chemotherapy (Arabinoside 300 mg, Dactinomycin 40 mg, VP-16 150 mg, 6- mercaptopurin 60 mg, dexametasone 3 mg). Ten days after completing the second cycle he had abdominal pain, low abdominal tenderness and a high fever. The WBC count in the peripheral blood was 210 cell/mm3. A CT scan demonstrated wall thickening of the terminal ileum and ascending colon, as well as 5 cm, and 6 cm sized homogeneous low-density areas in both hepatic lobes. A presumptive diagnosis was neutropenic enterocolitis with a liver abscess. The patient was managed conservatively with fluid resuscitation, a bowel rest, and broad-spectrum antibiotics. Twenty-five days later his abdominal pain was abruptly aggravated. The CT scan and Chest X-ray demonstrated free air in the peritoneal cavity. An emergency laparotomy was performed under a diagnosis of peritonitis with an intestinal perforation. The laparotomy show that, there were perforations at the pylorus of the stomach, and full thickness necrosis at multiple segments of the small bowel. Primary closure of the stomach, a segmental resection and an end-to-end anastomosis of the small bowel, and ileostomy were performed. However, postoperative leakage developed at the stomach. The patient recovered with supportive management. The patient had a third chemotherapy series 3 months after surgery. Three days after completing the third cycle, the patient developed peritonitis. A pyloric re-perforation of the stomach was observed on the laparotomy. Postoperative leakage developed after the primary closure of the stomach. The patient died of sepsis 54 days later. Therefore, intensive monitoring and close collaboration between the hematologist and the surgeon is essential for patients with neutropenic enterocolitis. Postoperative complications are quite common and can be fatal in patients with neutropenic enterocolitis that develops after chemotherapy.