S3388 Tormenting Typhlon: A Rare Case

Abstract

INTRODUCTION: Neutropenic enterocolitis is acute inflammation of cecum, ascending colon, terminal ileum and appendix, seen in immunocompromised patients with leukemia. Incidence in healthy adults unknown, few cases due to clostridium perfringens type A. More seen in neutropenic children/adults who had undergone induction chemotherapy for acute leukemia, lymphoma, multiple myeloma, myelodysplastic syndromes, aplastic anemia, acquired immunodeficiency syndrome, cyclic or drug induced neutropenia or immunosuppressive therapy. Frequency is increasing with use of cytotoxic agents. CASE DESCRIPTION/METHODS: 48 year old male with no history presented with 8 days of worsening abdominal pain, few days of watery brown diarrhea, no neutropenia. CT showed acute appendicitis, perforation, periappendiceal collection and marked inflammatory reaction. Patient was taken for laparoscopic appendectomy. There was generalized peritonitis, pus with feculent odor. Appendix was inflamed, not perforated. Cecum had areas with false membrane consistent with cecal gangrene. Abscess posterior to cecum was fusing medially towards mesentery of small bowel and ascending colon. Right hemicolectomy with ileal transverse anastomosis was done. Pathology consistent with gangrenous typhlitis with retroperitoneal abscess. Intraop cultures were positive for ecoli. Patient was treated with IV antibiotics and then oral. DISCUSSION: Typhlitis, is neutropenic enterocolitis of ileocecal region. Cecum is affected due to diminished vascularization. Signs & symptoms: right lower quadrant pain, fever, abdominal distention, cramping, tenderness, nausea, vomiting, diarrhea, and hematochezia. Histology: bowel wall thickening, ulcers, mucosal loss, intramural edema, hemorrhage and necrosis. Patients suspected of typhlitis should have oral & IV contrast for CT. Blood & stool cultures, and C dificile toxin testing. CT can show bowel wall thickening, bowel dilation, mesenteric stranding, mucosal enhancement and pneumatosis. Cultures positive for polymicrobial infection. Treatment in patients without complications: bowel rest, NG suction, IV fluids, nutritional support & broad spectrum antibiotics covering pseudomonas, e coli, gram-negative bacilli & anaerobes. Surgical intervention if signs of perforation, bleeding despite correction of coagulopathy and cytopenias. It mimics appendicitis like in our patient leading to immediate surgery. It is important to consider neutropenic enterocolitis in the differential diagnosis of patients that are not immunocompromised.Figure 1Figure 2