Isolated Fever as a Rare Presentation of Bevacizumab-induced Colonic Perforation

Abstract

Purpose: Bowel perforation is a rare complication of the vascular endothelial growth factor inhibitor, bevacizumab (Avastin), in the treatment of metastatic colon cancer. We report a case of colonic perforation due to bevacizumab with subsequent abscess formation, presenting as isolated fever. Case: A 75-year-old man with recurrent colon adenocarcinoma after a left hemicolectomy with primary anastomosis eight months earlier for Dukes C colon adenocarcinoma presented to the emergency department with a one-day history of fever. He also had complaints of fatigue and diarrhea for a week. He denied abdominal pain, nausea, vomiting, and constipation. Three weeks prior, he had completed his first cycle of capecitabine, oxaliplatin, and bevacizumab for recurrent disease with metastasis. On examination, he was febrile, with a temperature of 39C, tachycardic to 101, but normotensive. He was otherwise comfortable and in no acute distress. Mild right lower abdominal tenderness was noted; no guarding or rebound tenderness. WBC 10,200/μL, otherwise laboratory studies were unremarkable. Abdominal radiograph revealed mild-to-moderate dilated small bowel with air-fluid levels; no evidence of pneumoperitoneum. He was initiated on broad-spectrum antibiotics. CT abdomen revealed a large, irregular air and fluid collection adjacent to the right psoas muscle, extending into the right iliac fossa with contrast extravasation. He underwent exploratory laparotomy, which revealed perforated ileocolic anastomosis with large posterior abdominal abscess with local tumour recurrence. Resection and end ileostomy was performed. Postoperatively, he did well, completed antibiotics, and was subsequently discharged home. Discussion: Our experience indicates that fever may be a sign of a serious complication of bevacizumab treatment. Perforated bowel resulting in abscess formation is associated with significant morbidity and mortality, and requires prompt medical and surgical attention. Clinicians must consider bowel perforation and abscess formation in the presence of fever in the setting of recent bevacizumab administration for metastatic colonic adenocarcinoma.