What's the diagnosis? By Dr. Abby Renko

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






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