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60. Typhlitis: A Real Pain in the Gut!
Keywords
TyphlitisNeutropenic enterocolitisIleocecal syndromeCytotoxic chemotherapyNeutropeniaNeutropenic feverOncologic emergencyCase
A 60-year-old female with a history of acute myelogenous leukemia (AML) presents to the emergency department with abdominal pain for the past 2 days. She is currently undergoing induction chemotherapy with cytarabine and daunorubicin with her last treatment being 10 days ago. She describes the pain as dull, constant, severe, and progressively worsening over the past 2 days. Her pain is localized to the right lower quadrant without radiation or obvious exacerbating or relieving factors. She also notes abdominal distension and profuse watery diarrhea with some bright red blood. She endorses subjective fever and chills at home.
Past medical history (PMH)
Acute myeloid leukemia (AML)
Past surgical history (PSH)
No prior surgical history.
Pertinent Physical Exam
Vital Signs: BP 95/56, HR 110, RR 18, Temp 102 °F.
General: Appears uncomfortable, holding her abdomen in bed.
Abdomen: Normoactive bowel sounds, soft, mildly distended, and exquisitely tender to palpation in the RLQ, no guarding or rebound tenderness, no masses or organomegaly.
Pertinent Diagnostic Testing
CBC, chem 10, hepatic function panel, lipase, lactate, type and cross, urinalysis (UA) + culture, C. diff stool assay, 2x blood cultures, and a CT abdomen and pelvis with oral and IV contrast were ordered. Significant findings are below.
Test | Result | Units | Normal range |
|---|---|---|---|
WBC | 2.0 | K/uL | 3.8–11.0 103/mm3 |
18% neutrophils, 1% bands, ANC 380 | |||
Hgb | 7.5 | g/dL | Male: 14–18 g/dL Female: 11–16 g/dL |
Lactate | 4.0 | mmol/L | < 2.0 mmol/L |
ED Management
The differential diagnosis included acute appendicitis, infectious colitis, ischemic colitis, perforated viscus, and typhlitis.
Fluid resuscitation and empiric broad-spectrum antibiotics to cover enteric bacteria and Pseudomonas aeruginosa were immediately initiated.
The CBC was notable for WBC count of 2000 cells/mm3 with 18% neutrophils, 1% bands, and an absolute neutrophil count (ANC) of 380 cells/mm3. The patient was placed on neutropenic precautions. The lactate was 4.0 mm/L, and the CT demonstrated dilation and wall thickening of the cecum with adjacent mesenteric fat stranding.
Learning Points
Priming Questions
1. What patient population is classically associated with typhlitis?
2. How do you determine if a patient is neutropenic?
3. What is the pathophysiology of typhlitis?
4. What are possible complications of typhlitis?
5. What are the important steps in managing neutropenic fever and typhlitis?
Introduction/Background
- 1.
Typhlitis, also known as neutropenic enterocolitis , is an acute inflammatory disorder of the bowels, usually affecting the cecum and ascending colon. The word “typhlitis” comes from the word “typhlon,” the Greek equivalent of the Latin term “cecum.” Typhlitis is an oncologic emergency and classically occurs in patients who are neutropenic after receiving cytotoxic chemotherapy for treatment of hematologic malignancy [1]. However, typhlitis may also occur in the setting of solid organ malignancy or other states of profound immunosuppression.
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