A 50 yo female with a history of pancreatic cancer, on chemotherapy presents to the ED with 3 days of subjective fever, worsening abdominal pain, and diarrhea.  Her abdomen is soft, but diffusely tender with voluntary guarding.  BP 109/78, HR 106, RR 20, T 99.7, SpO2 98%RA.  On chart review you see that the patient had chemotherapy 2 weeks ago and was leukopenic on her last out patient lab draw 5 days ago.  A CT with IV contrast is shown.  What's the diagnosis? Scroll down for answer.

Answer: Neutropenic Enterocolitis (ie typhilitis)

• What is it
• a life-threatening bowel infection that occurs primarily in neutropenic patients (usually those on chemotherapy, transplant recipients, those with leukemia or other underlying immunocompromise)
• should be in differential diagnosis for ANY immunocompromised patient with abdomnal pain +/- fever, diarrhea, GI bleed
• Other synonymous terms
• necrotizing enterocolitis
• typhilitis
• neutropenic colitis
• ileocecal syndrome
• Pathogenesis
• neutropenia (ie impaired host defense to microorganisms) + mucosal injury by cytotoxic drugs or other means leads to microbial infection which evolves to necrosis of bowel wall layers
• Diagnosis
• ANC < 500 cells/microL
• typically made with CT scan, ideally both PO and IV contrast
• CT findings
• bowel wall thickening (100% of cases)
• mesenteric stranding and bowel dilation (50%)
• mucosal enhancement and pneumotosis (air in bowel wall) (~1/3 patients)
• Treatment
• non surgical - bowel rest, NGT, broad spectrum antibiotics
• example regimens
• piperacillin- tazobactam
• cefepime + metronidazole
• meropenem or imipenem
• in patients with persistant fever for 72 hours despite broad spectrum antibiotics, consider adding anti fungal
• surgical - for complications such as perforation

References:

Song et al. Neutropenic enterocolitis (typhilitis). In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on November 2, 2021.)