Neutropenic Enterocolitis in Leukemia

Infect Med. 2002;19(9) 

Introduction

Neutropenic enterocolitis (typhlitis) is a transmural necrotizing infection of the cecum that may progress to perforation, peritonitis, fistulous communications, and sepsis. It remains a potentially lethal complication in patients receiving chemotherapy, especially for hematologic malignancies. Early broad-spectrum antibiotic coverage for gram-negative and anaerobic organisms is paramount. Organisms isolated most frequently from blood cultures are Clostridium and enteric gram-negative bacilli. Symptoms and physical findings referable to the right lower quadrant of the abdomen are suggestive of typhlitis. CT scans are much more likely than routine x-ray films to detect the pathognomonic bowel thickening. Among 39 typhlitis cases recently reviewed at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla, 18 were in patients with acute myelogenous leukemia with secondary febrile neutropenia. Two cases are illustrated here.

A 22-year-old man with nodular sclerosing Hodgkin lymphoma was hospitalized a third time for neutropenic fever. He complained of nausea, vomiting, and diarrhea. Physical examination revealed right lower quadrant abdominal pain, guarding, and rebound tenderness, while a CT scan (Figure 1) showed a markedly thickened cecum and inflammatory changes in the pericecal tissue. On the second day, he complained of numbness in the right groin and lateral upper thigh. One day after resection of an unperforated cecum and creation of a colostomy, ecchymoses and large hemorrhagic bullae appeared on the thigh (Figure 2). Despite aggressive treatment with appropriate antibiotics, dopamine, and norepinephrine, he soon died of septic shock. Results of blood and urine cultures were negative.

A 59-year-old man was sent home after deferring therapy for a relapse of multiple myeloma. Twelve days later he returned, complaining of right lower quadrant pain and tenderness, nausea, vomiting, and watery diarrhea; he was admitted with a diagnosis of neutropenic fever. Blood cultures grew Clostridium septicum, Escherichia coli, and Klebsiella. Eight hours after admission, he was found in cardiorespiratory arrest and could not be resuscitated. At autopsy, macroscopic examination revealed a very inflamed cecum and proximal right colon, with peritoneal injection, prominent mucosal edema, and hemorrhage (Figure 3). Focal pseudomembrane formation and thinning of the bowel wall suggested regional necrosis. Microscopic evaluation found multiple foci of adherent fibrinopurulent exudate over a widely necrotic and edematous mucosa, confirming the diagnosis of neutropenic enterocolitis.

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