Diverticulitis in the Neutropenic Patient: Case Report and Literature Review

Abstract

Diverticulitis is a common gastrointestinal disease, however, it is rarely described in patients with immunosuppression. Neutropenic patients with fever and abdominal symptoms such as pain, diarrhea and rectal bleeding are considered to have C difficile colitis or typhlitis. However a third possibility is diverticulitis which can lead to perforation and sepsis. Acute diverticulitis in the setting of neutropenia is rarely reported in literature. An 82 year old male presented with a 1 month history of abdominal pain accompanied by fevers, anorexia, emesis, and constipation. He was previously treated with decitabine for acute myeloid leukemia leading to a 4 month history of neutropenia with an absolute neutrophil count less than 100x103/μL. He reported a prior history of diverticulosis and a single episode of prior diverticulitis managed conservatively with oral antibiotics one year ago. He denied use of nonsteroidal anti-inflammatory drugs, tobacco or alcohol. On admission, blood cultures were negative and a CT of the abdomen and pelvis revealed severe sigmoid diverticulitis. The patient was started on piperacillin/tazobactam which was transitioned to ciprofloxacin and metronidazole after 8 days of therapy. He developed worsening abdominal pain and repeat imaging revealed progression of sigmoid diverticulitis without evidence of abscess; therapy was escalated to piperacillin/tazobactam. Fluconazole prophylaxis was begun and clostridium difficile testing was negative. A repeat CT scan 19 days after admission revealed perforation of the sigmoid with several fluid collections concerning for abscess formation. Surgery recommended against operative intervention or CT guided drainage due to pancytopenia. Antibiotics were transitioned to meropenem and metronidazole. His condition continued to deteriorate and he was discharged home with hospice and no antibiotics.Figure 1Figure 2Figure 3Typically, patients improve when their neutropenia resolves. This case exemplifies a rare occurrence of diverticulitis in a patient with prolonged neutropenia. It illustrates the complications associated with this disease including abscess formation and perforation. Unfortunately, this patient's severe disease precluded him from any aggressive surgical intervention and conservative therapy failed. This disease pattern necessitates provider familiarity for optimal therapy, the role of surgical drainage, and patient outcomes in the setting of prolonged neutropenia and thrombocytopenia.