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Xia R, Zhang X. Neutropenic enterocolitis: A clinico-pathological review. World J Gastrointest Pathophysiol 2019; 10:36-41. [PMID: 31692935 PMCID: PMC6829094 DOI: 10.4291/wjgp.v10.i3.36] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/06/2019] [Accepted: 09/22/2019] [Indexed: 02/06/2023] Open
Abstract
Neutropenic enterocolitis (NE) is a predominantly cecum-based disease with high mortality seen in patients post chemotherapy. The pathogenesis of NE is poorly understood and probably multifactorial involving mucosal injury, neutropenia, and impaired host defense to intestinal organisms. The clinical presentation is characterized as ileocolonic inflammation and bowel wall thickening in patients with neutropenia, fever, and abdominal pain. The pathological features of NE include patchy necrosis, hemorrhage, ulcer, edema, perforation, infiltrating organisms, and characteristically, depletion of inflammatory cells (neutrophils). NE should always be considered as a possible diagnosis in immunosuppressed patients, especially those receiving chemotherapy. High clinical and histological diagnostic discordance rate exists. High index of clinical suspicion and prompt appropriate personalized management are essential to achieve a lower mortality rate.
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Affiliation(s)
- Rong Xia
- Department of Pathology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06520, United States
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Singh P, Nayernama A, Christopher Jones S, Amiri Kordestani L, Fedenko K, Prowell T, Bersoff-Matcha SJ. Fatal neutropenic enterocolitis associated with docetaxel use: A review of cases reported to the United States Food and Drug Administration Adverse Event Reporting System. J Oncol Pharm Pract 2019; 26:923-928. [PMID: 31594460 DOI: 10.1177/1078155219879494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Docetaxel is a microtubule inhibitor indicated for the treatment of multiple cancers as a single agent or in combination with other antineoplastics. The U.S. Food and Drug Administration (FDA) conducted a postmarketing review of fatal neutropenic enterocolitis cases reported with docetaxel using the FDA Adverse Event Reporting System (FAERS) and literature to determine whether the drug was a potential cause. We searched FAERS and the literature for reports of fatal neutropenic enterocolitis with docetaxel-based treatment reported between 14 May 1996 and 13 March 2017. We characterized the clinical course and severity of neutropenic enterocolitis and utilized the World Health Organization-Uppsala Monitoring Centre rubric to assess drug causality. We identified 41 fatal cases of neutropenic enterocolitis with docetaxel from FAERS and the literature. The median time to onset of neutropenic enterocolitis from last docetaxel dose was seven days (range 2-13 days), and median time to death was nine days (range 3-23 days). The cause of death in 83% (34/41) of patients was neutropenic enterocolitis. We determined the drug-event association as probable in seven cases. Neutropenic enterocolitis with docetaxel monotherapy occurred in six cases; however, in 85% (35/41) of cases, neutropenic enterocolitis occurred when docetaxel was used in combination with other cytotoxic chemotherapy. In some cases, neutropenic enterocolitis occurred despite use of granulocyte colony-stimulating factors. Neutropenic enterocolitis is a severe and potentially fatal complication of docetaxel-based treatment, especially when combined with other antineoplastic treatments known to cause neutropenia. Practitioners should be aware of this safety risk to promptly recognize and manage patients.
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Affiliation(s)
- Pritpal Singh
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Afrouz Nayernama
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - S Christopher Jones
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Laleh Amiri Kordestani
- Division of Oncology Products, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Katherine Fedenko
- Division of Oncology Products, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Tatiana Prowell
- Division of Oncology Products, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Susan J Bersoff-Matcha
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
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Guerri S, Danti G, Frezzetti G, Lucarelli E, Pradella S, Miele V. Clostridium difficile colitis: CT findings and differential diagnosis. Radiol Med 2019; 124:1185-1198. [PMID: 31302848 DOI: 10.1007/s11547-019-01066-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022]
Abstract
Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.
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Affiliation(s)
- Sara Guerri
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - Ginevra Danti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Gianluca Frezzetti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Edvige Lucarelli
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Silvia Pradella
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy.
| | - Vittorio Miele
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
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An imaging-based review of systemic therapies and associated toxicities in metastatic pancreatic cancer as per the 2018 ASCO guidelines: what every radiologist should know. Abdom Radiol (NY) 2019; 44:2182-2195. [PMID: 30820626 DOI: 10.1007/s00261-019-01954-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide an overview of what radiologists should know about systemic agents utilized in the modern treatment of metastatic pancreatic cancer and their associated toxicities. RESULTS The clinical landscape of metastatic pancreatic cancer has significantly evolved in recent years, with the advent of new first- and second-line systemic therapies. As these systemic treatment options continue to expand, knowledge of their clinically relevant features is becoming critical for radiologists. While the issues of surgical resectability and tumor response evaluation of advanced stages of pancreatic cancer have been thoroughly discussed in the radiology literature, the diagnostic importance of systemic therapies has tended to be less well appreciated. In this review, we provide a primer for radiologists outlining the radiologically pertinent features of modern systemic therapies used in the treatment of metastatic pancreatic ductal adenocarcinoma. These systemic agents are discussed from the standpoint of the newly updated 2018 ( https://doi.org/10.1007/s00261-019-01954-z ) guidelines for the treatment of metastatic pancreatic cancer from the American Society of Clinical Oncology (ASCO). Understanding the radiology relevance of these modern therapeutic agents is critical, especially with regard to treatment response and toxicity assessment. CONCLUSION Knowledge of the modern systemic therapies utilized in the treatment of metastatic pancreatic cancer and their associated toxicity profiles is critical in diagnostic imaging interpretation.
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Duceau B, Picard M, Pirracchio R, Wanquet A, Pène F, Merceron S, Mokart D, Moreau AS, Lengliné E, Canet E, Lemiale V, Mariotte E, Azoulay E, Zafrani L. Neutropenic Enterocolitis in Critically Ill Patients: Spectrum of the Disease and Risk of Invasive Fungal Disease. Crit Care Med 2019; 47:668-676. [PMID: 30741755 DOI: 10.1097/ccm.0000000000003687] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Neutropenic enterocolitis occurs in about 5.3% of patients hospitalized for hematologic malignancies receiving chemotherapy. Data from critically ill patients with neutropenic enterocolitis are scarce. Our objectives were to describe the population of patients with neutropenic enterocolitis admitted to an ICU and to investigate the risk factors of invasive fungal disease. DESIGN A multicentric retrospective cohort study between January 2010 and August 2017. SETTING Six French ICUs members of the Groupe de Recherche Respiratoire en Onco-Hématologie research network. PATIENTS Adult neutropenic patients hospitalized in the ICU with a diagnosis of enteritis and/or colitis. Patients with differential diagnosis (Clostridium difficile colitis, viral colitis, inflammatory enterocolitis, mesenteric ischemia, radiation-induced gastrointestinal toxicity, and Graft vs Host Disease) were excluded. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS We included 134 patients (median Sequential Organ Failure Assessment 10 [8-12]), with 38.8% hospital mortality and 32.1% ICU mortality rates. The main underlying malignancies were acute leukemia (n = 65, 48.5%), lymphoma (n = 49, 36.6%), solid tumor (n = 14, 10.4%), and myeloma (n = 4, 3.0%). Patients were neutropenic during a median of 14 days (9-22 d). Infection was documented in 81 patients (60.4%), including an isolated bacterial infection in 64 patients (47.8%), an isolated fungal infection in nine patients (6.7%), and a coinfection with both pathogens in eight patients (5.0%). Radiologically assessed enteritis (odds ratio, 2.60; 95% CI, 1.32-7.56; p = 0.015) and HIV infection (odds ratio, 2.03; 95% CI, 1.21-3.31; p = 0.016) were independently associated with invasive fungal disease. CONCLUSIONS The rate of invasive fungal disease reaches 20% in patients with neutropenic enterocolitis when enteritis is considered. To avoid treatment delay, antifungal therapy might be systematically discussed in ICU patients admitted for neutropenic enterocolitis with radiologically assessed enteritis.
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Affiliation(s)
- Baptiste Duceau
- Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, France
- Paris Diderot University, Paris, France
| | - Muriel Picard
- Intensive Care Unit, CHU de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Romain Pirracchio
- Anesthesiology and Surgical Intensive Care Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- Department of Biostatistics and Medical Informatics, INSERM U-1153, Paris, France
| | - Anne Wanquet
- Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Hospital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sybille Merceron
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Djamel Mokart
- Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | | | - Etienne Lengliné
- Department of Hematology, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, France
- Paris Diderot University, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, France
- Paris Diderot University, Paris, France
| | - Eric Mariotte
- Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, France
- Paris Diderot University, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, France
- Paris Diderot University, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique-Hôpitaux de Paris, France
- Paris Diderot University, Paris, France
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Management of Pneumatosis Intestinalis in Neutropenic Acute Leukemia Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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A Novel Severity Score Index for Febrile Neutropenic Patients with Colorectal Diseases. Gastroenterol Res Pract 2019; 2019:4175960. [PMID: 31019530 PMCID: PMC6451812 DOI: 10.1155/2019/4175960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/15/2019] [Indexed: 01/03/2023] Open
Abstract
Introduction Abdominal and anorectal disorders may be the cause of clinical decompensation in neutropenic febrile patients, particularly those with hematologic diseases. Infection is a cause for concern for the colorectal surgeon. Some conditions have few manifestations and can lead to death within a short period of time. This study presents the novel colorectal disorder severity score for febrile neutropenic patients. Materials and Methods This was a case series study analyzing the medical records of 897 patients admitted to the Hematology and Hematopoietic Stem Cell Transplant Unit in a university hospital between the years 2008 and 2013. Seventy-four episodes of febrile neutropenia in 69 patients diagnosed with an abdominal or anorectal infection site were eligible for the study. The new scoring system proposed here is based on the author's clinical experience and an extensive literature review. In addition to the extensive literature review, effect measures were calculated, and a statistical analysis was performed. Based on an evaluation of common biological plausibility criteria, five factors were selected as the main predictors of hospital mortality in febrile neutropenic patients with colorectal disease. Results The proposed score demonstrated increased mortality as the condition worsened as reflected by an increasing score (Fisher's exact test: 0.001). When considering the logistic model for the probability of death by score level, the AUC value was 0.82 (0.72-0.925), and the Hosmer-Lemeshow statistic value was 2.3, p = 0.806. Conclusion The proposed scoring system allows prediction of the likelihood of death during hospitalization for febrile neutropenic patients with an abdominal and anorectal focus. New studies on the subject are required, and the proposed scoring scale must be validated on a larger and different sample of patients.
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Abu-Sbeih H, Ali FS, Qiao W, Lu Y, Patel S, Diab A, Wang Y. Immune checkpoint inhibitor-induced colitis as a predictor of survival in metastatic melanoma. Cancer Immunol Immunother 2019; 68:553-561. [PMID: 30666357 PMCID: PMC11028302 DOI: 10.1007/s00262-019-02303-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastrointestinal (GI) immune-related adverse events (irAEs) commonly limit immune checkpoint inhibitors' (ICIs) treatment, which is very effective for metastatic melanoma. The independent impact of GI-irAEs on patients' survival is not well studied. We aimed to assess the impact of GI-irAEs on survival rates of patients with metastatic melanoma using multivariate model. METHODS This is a retrospective study of patients with metastatic melanoma who developed GI-irAEs from 1/2010 through 4/2018. A number of randomized patients who did not have GI-irAEs were included as controls. Kaplan-Meier curves and log-rank test were used to estimate unadjusted survival durations. The Cox proportional hazards model was used to evaluate survival predictors; irAEs were included as time-dependent variables. RESULTS A total of 346 patients were included, 173 patients had GI-irAEs; 124 (72%) received immunosuppression. In multivariate Cox regression, ECOG 2-3 (HR 2.57, 95%CI 1.44-4.57; P < 0.01), LDH ≥ 618 IU/L (HR 2.20, 95% CI 1.47-3.29; P < 0.01), stage M1c (HR 2.21, 95% CI 1.35-3.60; P < 0.01) were associated with worse OS rates. Any grade GI-irAEs (HR 0.53, 95% CI 0.36-0.78; P < 0.01) was associated with improved OS rates. Immunosuppressive treatment did not affect OS (P = 0.15). High-grade diarrhea was associated with improved OS (P = 0.04). Patients who developed GI-irAEs had longer PFS durations on Cox model (HR 0.56, 95% CI 0.41-0.76; P < 0.01). CONCLUSION GI-irAEs are associated with improved OS and PFS in patients with metastatic melanoma. Furthermore, higher grades of diarrhea are associated with even better patients' OS rates.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Faisal S Ali
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Wei Qiao
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yang Lu
- Department of Nuclear Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Sapna Patel
- Department of Melanoma Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Febrile Neutropenia in Transplant Recipients. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7122322 DOI: 10.1007/978-1-4939-9034-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Febrile neutropenic patients are at increased risk of developing infections. During the initial stages of neutropenia, most of these infections are bacterial. The spectrum of bacterial infections depends to some extent on whether or not patients receive antimicrobial prophylaxis when neutropenic. Since most transplant recipients do, Gram-positive organisms predominate, due to the fact prophylaxis is directed primarily against Gram-negative organisms. Staphylococcus species (often methicillin-resistant), Streptococcus species (viridans group streptococci, beta-hemolytic streptococci), and Enterococcus species (including vancomycin-resistant strains) are isolated most often. Therefore, potent empiric Gram-positive coverage is recommended by many in this setting. Escherichia coli, Pseudomonas aeruginosa, and Klebsiella species are the most common Gram-negative pathogens isolated. Non-fermentative Gram-negative bacilli (Stenotrophomonas maltophilia, Acinetobacter species) are emerging as important pathogens. Many of these organisms acquire multiple mechanisms of resistance that render them multidrug resistant. The administration of prompt, broad-spectrum, empiric, antimicrobial therapy is essential and is generally based on local epidemiology and susceptibility/resistance patterns. Response rate to the initial regimen is generally in the range of 75–85%. Fungal infections develop in patients with prolonged neutropenia (greater than 7–10 days). Candida species and Aspergillus species are the predominant fungal pathogens, although many other fungi are opportunistic pathogens in this setting. Fungal infections are seldom documented microbiologically or on histopathology, and the administration of empiric antifungal therapy, when such infections are suspected, is the norm. Therapy is often prolonged, and outcomes are still suboptimal. The importance of infection control and antimicrobial stewardship cannot be overemphasized.
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Hesla AC, Bruland ØS, Jebsen N, Styring E, Eriksson S, Tsagozis P. Ewing sarcoma of the mobile spine; predictive factors for survival, neurological function and local control. A Scandinavian sarcoma group study with a mean follow-up of 12 years. J Bone Oncol 2018; 14:100216. [PMID: 30666289 PMCID: PMC6329704 DOI: 10.1016/j.jbo.2018.100216] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/10/2018] [Accepted: 12/24/2018] [Indexed: 01/03/2023] Open
Abstract
Object: Many patients with Ewing sarcoma (ES) of the mobile spine present with neurologic symptoms leading to emergency decompressive surgery. Only rarely is optimal treatment involving neo-adjuvant chemotherapy followed by en bloc excision possible. The purpose of this study was to study treatment, neurologic and oncologic outcome in patients with ES of the mobile spine. Methods: Twenty-four patients diagnosed between 1986 and 2012 were identified through the Scandinavian Sarcoma Group registry. Charts were reviewed in order to assess details in patient characteristics, neurologic status, treatment and outcome. Prognostic factors were analyzed with respect to local control, disease-free survival and overall survival. Results: Neurologic symptoms were frequently observed at presentation, being present in 19/23 patients with documented neurologic status. Most (13/19) patients had a complete neurologic recovery regardless of whether or not emergency decompressive surgery was performed. The majority (18/24) of patients were treated with definitive radiotherapy. However, only 9/17 received the recommended dose of ≥ 50.4 Gy. The disease-free and overall survival rates at 10 years were 48% and 57%, respectively. The local recurrence rates were 19% and 27% at 5 and 10 years, respectively. Only year of diagnosis, categorized into periods with significant changes in chemotherapy protocols, was a significant factor for local recurrence, but there was a trend (p = 0.06) for an increased risk of a local recurrence if emergency decompressive surgery was performed. Conclusion: Patients with ES of the mobile have a relatively favorable prognosis. Nonetheless, local recurrence rate is high for this group of patients for which local treatment mainly relies on definitive radiotherapy. Emergency decompressive surgery may increase the risk for local recurrence.
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Affiliation(s)
- Asle Charles Hesla
- Institute of Molecular Medicine and Surgery, Karolinska Institute & Karolinska University Hospital, 17176 Solna, Sweden
| | - Øyvind Sverre Bruland
- Department of Oncology, Institute for Clinical Medicine, University of Oslo, Oslo University Hospital - Norwegian Radium Hospital, 0310 Oslo, Norway
| | - Nina Jebsen
- Department of Oncology, Haukeland University Hospital, Centre for Cancer Biomarkers University of Bergen, 5021 Bergen, Norway
| | - Emelie Styring
- Department of Orthopaedic Surgery, Skåne University Hospital, Getingevägen 4, 222 41 Lund, Sweden
| | - Sigvard Eriksson
- Department of Orthopaedic Surgery, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - Panagiotis Tsagozis
- Department of Orthopaedic Surgery, Karolinska University Hospital, 17176 Solna, Sweden
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Kaito S, Sekiya N, Najima Y, Sano N, Horiguchi S, Kakihana K, Hishima T, Ohashi K. Fatal Neutropenic Enterocolitis Caused by Stenotrophomonas maltophilia: A Rare and Underrecognized Entity. Intern Med 2018; 57:3667-3671. [PMID: 30101922 PMCID: PMC6355424 DOI: 10.2169/internalmedicine.1227-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Although Stenotrophomonas maltophilia causes substantial morbidity and mortality in immunocompromised patients, it has not been described as a causal pathogen of neutropenic enterocolitis (NEC). We describe the first case of histologically-confirmed NEC caused by S. maltophilia accompanied by bacteremia and pneumonia after salvage chemotherapy for acute myeloid leukemia relapse following a second hematopoietic stem cell transplantation. S. maltophilia should be included as a pathogenic organism of NEC in severely immunocompromised patients to prevent a delayed diagnosis, which carries a high risk of inappropriate antimicrobial selection and fatal outcome.
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Affiliation(s)
- Satoshi Kaito
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
- Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Noritaka Sekiya
- Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
- Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Yuho Najima
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Naoki Sano
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Shinichiro Horiguchi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Kazuhiko Kakihana
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Tsunekazu Hishima
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Kazuteru Ohashi
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
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Bossi P, Antonuzzo A, Cherny NI, Rosengarten O, Pernot S, Trippa F, Schuler U, Snegovoy A, Jordan K, Ripamonti CI. Diarrhoea in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv126-iv142. [PMID: 29931177 DOI: 10.1093/annonc/mdy145] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- P Bossi
- Head and Neck Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano
| | - A Antonuzzo
- U.O. Oncologia Medica 1, Polo Oncologico Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - N I Cherny
- Oncology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - O Rosengarten
- Oncology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - S Pernot
- Department of Hepato-Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - F Trippa
- Radiation Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - U Schuler
- Department of Internal Medicine I, Palliative Care Centre, University Hospital Carl Gustav Carus, Dresden, Germany
| | - A Snegovoy
- N.N. Blokhin Russian Cancer Research Center, Moscow, Russia
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - C I Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Park JW, Chung JS, Lee S, Shin HJ. Neutropenic Enterocolitis due to Mucormycosis in a Patient with Myelodysplastic Syndrome. Infect Chemother 2018; 52:98-104. [PMID: 31668023 PMCID: PMC7113448 DOI: 10.3947/ic.2020.52.1.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/16/2017] [Indexed: 12/12/2022] Open
Abstract
Neutropenic enterocolitis is a fatal enterocolitis occurring in neutropenic patients with immunocompromised diseases including hematologic malignancies. Gastrointestinal (GI) mucormycosis in hematologic malignancies has been rarely reported. Especially, in myelodysplastic syndrome (MDS), GI mucormycosis has never been reported. We report a case of GI mucormocysis manifesting as neutropenic enterocolitis in a patient with MDS.
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Affiliation(s)
- Joon Woo Park
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Joo Seop Chung
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Shinwon Lee
- Division of Infectious Diseases, Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ho Jin Shin
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.
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Abstract
Oncology patients are a unique patient population in the emergency department (ED). Malignancy and associated surgical, chemotherapeutic, or radiation therapies put them at an increased risk for infection. The most ominous development is neutropenic fever, which happens often and may not present with signs or symptoms other than fever. A broad differential diagnosis is essential when considering infectious disease pathology in both neutropenic and non-neutropenic oncology patients in the ED.
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Affiliation(s)
- Lauren Cantwell
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24014, USA
| | - Jack Perkins
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24014, USA.
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Khan MS, Khan Z, Khateeb F, Moustafa A, Taleb M, Yoon Y. Recurrent Levamisole-Induced Agranulocytosis Complicated by Bowel Ischemia in a Cocaine User. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:630-633. [PMID: 29853712 PMCID: PMC6009213 DOI: 10.12659/ajcr.908898] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/05/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United States contains levamisole. It is a synthetic imidazothiazole derivative which was previously used as an immunomodulating agent for treatment of various connective tissue disorders and colorectal carcinoma. However, it was withdrawn later from the market due to significant toxicity associated with it. CASE REPORT We present the case of a 59-year-old male patient with a history of active cocaine use who presented to the hospital with febrile neutropenia and agranulocytosis. He underwent extensive work-up for neutropenia and was suspected to have it secondary to levamisole-adulterated cocaine. He was treated with antibiotics and granulocyte-stimulating factor. His white cell count improved and he was discharged home. He continued to use cocaine after discharge from the hospital. He returned to the hospital 3 weeks later with recurrent neutropenia and agranulocytosis complicated by septic shock and bowel necrosis which required prolonged antibiotics and a bowel resection. CONCLUSIONS Levamisole-induced agranulocytosis should be considered in patients who present with neutropenia and a history of cocaine use. Physicians should have high clinical suspicion and consider it a potential etiology of agranulocytosis when other causes have been excluded.
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Affiliation(s)
- Mohammad Saud Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Zubair Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Faisal Khateeb
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Abdelmoniem Moustafa
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Mohammad Taleb
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
| | - Youngsook Yoon
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Toledo Medical Center, Toledo, OH, U.S.A
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67
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Miller EE, Reardon LC. Neutropenic Enterocolitis in a Pediatric Heart Transplant Recipient on Multiple Immunosuppressants. Case Rep Transplant 2018; 2018:3264921. [PMID: 29854547 PMCID: PMC5964482 DOI: 10.1155/2018/3264921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/18/2018] [Accepted: 04/03/2018] [Indexed: 12/11/2022] Open
Abstract
Neutropenic enterocolitis (NE) historically primarily affects pediatric patients with leukemia who are undergoing chemotherapy or who have recently received bone marrow transplants. Although a few case reports have shown NE occurring outside of this typical population, to our knowledge, this is the first published case of NE occurring in the setting of pediatric heart transplant. This patient was diagnosed several months after pediatric heart transplant, with radiographs showing evidence of pneumatosis intestinalis. Although NE does not typically affect solid organ transplant patients, this patient had a variety of risk factors that may have predisposed her to development of NE such as severe neutropenia, supratherapeutic tacrolimus level, immunosuppression with cytotoxic agents, and elevated Epstein-Barr viral load. Fortunately, this patient improved with bowel rest, fluids, antibiotics, and alteration of her immunosuppressive regimen. However, NE can be fatal, and thus it is an important condition to consider, even in patients without leukemia or on chemotherapeutic regimens.
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Affiliation(s)
- Emily E. Miller
- UCLA Mattel Children's Hospital, Pediatric Heart Transplant Program, 200 UCLA Medical Plaza Suite 330, Los Angeles, CA 90024, USA
| | - Leigh Christopher Reardon
- UCLA Mattel Children's Hospital, Pediatric Heart Transplant Program, 200 UCLA Medical Plaza Suite 330, Los Angeles, CA 90024, USA
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Ramos Martínez A, Pintos Pascual I, Múñez Rubio E. [Infections in immunocompromised patients (II). The transplanted patient]. Medicine (Baltimore) 2018; 12:3245-3252. [PMID: 32287906 PMCID: PMC7143593 DOI: 10.1016/j.med.2018.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Los receptores de los diferentes tipos de trasplante presentan un riesgo elevado de infección. En los trasplantados de precursores hematopoyéticos predominan las infecciones nosocomiales. Durante el periodo posprendimiento temprano (30-100 días tras la infusión del trasplante), la incidencia de infección es más elevada en pacientes con enfermedad de injerto contra huésped. En el pulmón pueden aparecer lesiones nodulares por infección fúngica invasora o bien un patón difuso habitualmente secundario a infección vírica o a neumonía por P. jirovecii. Después de los primeros 100 días persiste un moderado riesgo de infección por microorganismos convencionales y oportunistas, como la infección tardía por CMV. Los avances en las técnicas quirúrgicas y el empleo de calcineurínicos han reducido la mortalidad por infecciones en trasplantados de órgano sólido. Durante el primer mes, son frecuentes las infecciones nosocomiales; entre el primer y sexto mes son más frecuentes las infecciones oportunistas dependientes de la inmunidad celular y a partir de sexto mes el riesgo baja y predominan las infecciones comunitarias semejantes a las de los pacientes inmunocompetentes.
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Affiliation(s)
- A. Ramos Martínez
- Unidad de Enfermedades Infecciosas. Servicio de Medicina Interna. Hospital Universitario Puerta de Hierro. Madrid. España
- Autor para correspondencia.
| | - I. Pintos Pascual
- Servicio de Medicina Interna. Hospital Universitario Fundación Jiménez Díaz. Madrid. España
| | - E. Múñez Rubio
- Unidad de Enfermedades Infecciosas. Servicio de Medicina Interna. Hospital Universitario Puerta de Hierro. Madrid. España
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Review of Appendicitis in Patients With Prolonged Neutropenia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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70
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Saillard C, Zafrani L, Darmon M, Bisbal M, Chow-Chine L, Sannini A, Brun JP, Ewald J, Turrini O, Faucher M, Azoulay E, Mokart D. The prognostic impact of abdominal surgery in cancer patients with neutropenic enterocolitis: a systematic review and meta-analysis, on behalf the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH). Ann Intensive Care 2018; 8:47. [PMID: 29675758 PMCID: PMC5908777 DOI: 10.1186/s13613-018-0394-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/12/2018] [Indexed: 12/15/2022] Open
Abstract
Neutropenic enterocolitis (NE) is a diagnostic and therapeutic challenge associated with high mortality rates, with controversial opinions on its optimal management. Physicians are usually reluctant to select surgery as the first-choice treatment, concerns being raised regarding the potential risks associated with abdominal surgery during neutropenia. Nevertheless, no published studies comforted this idea, literature is scarce and surgery has never been compared to medical treatment. This review and meta-analysis aimed to determine the prognostic impact of abdominal surgery on outcome of neutropenic cancer patients presenting with NE, versus medical conservative treatment. This meta-analysis included studies analyzing cancer patients presenting with NE, treated with surgical or medical treatment, searched by PubMed and Cochrane databases (1983–2016), according to PRISMA recommendations. The endpoint was hospital mortality. Fixed-effects models were used. The meta-analysis included 20 studies (385 patients). Overall estimated mortality was 42.2% (95% CI = 40.2–44.2). Abdominal surgery was associated with a favorable outcome with an OR of 0.41 (95% CI = 0.23–0.74; p = 0.003). Pre-defined subgroups analysis showed that neither period of admission, underlying malignancy nor neutropenia during the surgical procedure, influenced this result. Surgery was not associated with an excess risk of mortality compared to medical treatment. Defining the optimal indications of surgical treatment is needed. Trial registration PROSPERO CRD42016048952
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Affiliation(s)
- Colombe Saillard
- Haematology Department, Institut Paoli Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille Cedex 09, France.
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Michael Darmon
- Medical-Surgical Intensive Care Unit, Hôpital Nord, Université Jean Monnet, Saint Etienne, France.,GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France
| | - Magali Bisbal
- GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France.,Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Antoine Sannini
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jean-Paul Brun
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jacques Ewald
- Surgery Department, Institut Paoli Calmettes, Marseille, France
| | - Olivier Turrini
- Surgery Department, Institut Paoli Calmettes, Marseille, France
| | - Marion Faucher
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France.,GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France.,Faculté de Médecine, Université Paris Diderot, Sorbonne-Paris-Cité, Paris, France
| | - Djamel Mokart
- GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France.,Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
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71
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Clinical Presentation, Prognostic Factors, and Outcome in Neutropenic Enteropathy of Childhood Leukemia. J Pediatr Hematol Oncol 2018; 40:216-220. [PMID: 29293190 DOI: 10.1097/mph.0000000000001065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Leukemia patients are at risk for neutropenic enteropathy (NEP) because of the effects of intensified chemotherapy. Medical records of 18 patients having 20 episodes of NEP were reviewed retrospectively. Primary diagnosis was acute lymphoblastic leukemia in 12 and myeloblastic leukemia in 6 cases. According to prognosis, 3 patients were in the standard-risk group, 6 in the moderate-risk group, and 9 in the high-risk group. Ultrasonography detected increased bowel wall thickness in 6 patients. Abdominal x-ray revealed air-fluid levels (n=8), pneumatosis intestinalis, pneumoperitoneum (n=1), and portal venous gas (n=1). All patients received medical treatment, and 1 with unrelieved hematochezia required resection of the cecum. Two cases with appendicitis and another 1 with pneumoperitoneum responded to antibiotics and recovered without surgery. The mortality rate was 30% and related to sepsis-induced complications. The presence of hypokalemia, hypoalbuminemia, metabolic acidosis, and admission to the intensive care unit were more common in patients with mortality (P=0.01). In conclusion, NEP should be kept in mind as a treatable but potentially lethal complication of childhood leukemia. Radiologic findings should be interpreted in conjunction with clinical picture. A conservative approach should be used in all cases but surgery can be considered in some situations.
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73
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Le Clech L, Talarmin JP, Couturier MA, Ianotto JC, Nicol C, Le Calloch R, Dos Santos S, Hutin P, Tandé D, Cogulet V, Berthou C, Guillerm G. Early discontinuation of empirical antibacterial therapy in febrile neutropenia: the ANTIBIOSTOP study. Infect Dis (Lond) 2018; 50:539-549. [PMID: 29451055 DOI: 10.1080/23744235.2018.1438649] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Immediate empirical antibiotic therapy is mandatory in febrile chemotherapy-induced neutropenia, but its optimal duration is unclear, especially in patients with fever of unknown origin (FUO). OBJECTIVES The primary objective of this 20-month prospective observational study was to evaluate the feasibility and safety of short-term antibiotic treatment in afebrile or febrile patients exhibiting FUO, irrespective of their neutrophil count. The secondary objective was to describe the epidemiology of all episodes of febrile neutropenia. METHODS In the first phase of the study, empirical antibiotic therapy in FUO patients was stopped after 48 h of apyrexia, in accordance with European Conference on Infections in Leukaemia guidelines (n = 45). In the second phase of the study, antibiotics were stopped no later than day 5 for all FUO patients, regardless of body temperature or leukocyte count (n = 37). RESULTS Two hundred and thirty-eight cases of febrile neutropenia in 123 patients were included. Neither the composite endpoint (p = .11), nor each component (in-hospital mortality (p = .80), intensive care unit admission (p = 0.48), relapse of infection ≤48 h after discontinuation of antibiotics (p = .82)) differed between the two FUO groups. Violation of protocol occurred in 17/82 episodes of FUO without any major impact on statistical results. Twenty-six (57.3%) and 22 (59.5%) FUO episodes did not relapse during hospital-stay (p = 1), and nine (20%) and five (13.5%) presented another FUO, respectively. One hundred and fifty-six episodes of febrile neutropenia (65.5%) were clinically or microbiologically documented, including 85 bacteremia. CONCLUSIONS These results suggest that early discontinuation of empirical antibiotics in FUO is safe for afebrile neutropenic patients.
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Affiliation(s)
- Lenaïg Le Clech
- a Department of Haematology , Brest Teaching Hospital , Brest , France.,b Department of Internal Medicine, Infectious Diseases and Haematology , Cornouaille Hospital Quimper , Quimper , France
| | - Jean-Philippe Talarmin
- b Department of Internal Medicine, Infectious Diseases and Haematology , Cornouaille Hospital Quimper , Quimper , France
| | | | | | - Christophe Nicol
- a Department of Haematology , Brest Teaching Hospital , Brest , France
| | - Ronan Le Calloch
- a Department of Haematology , Brest Teaching Hospital , Brest , France
| | | | - Pascal Hutin
- b Department of Internal Medicine, Infectious Diseases and Haematology , Cornouaille Hospital Quimper , Quimper , France
| | - Didier Tandé
- c Laboratory of Bacteriology , Brest Teaching Hospital , Brest , France
| | - Virginie Cogulet
- d Department of Pharmacy , Brest Teaching Hospital , Brest , France
| | - Christian Berthou
- a Department of Haematology , Brest Teaching Hospital , Brest , France
| | - Gaëlle Guillerm
- a Department of Haematology , Brest Teaching Hospital , Brest , France
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74
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Naymagon S, Naymagon L, Wong SY, Ko HM, Renteria A, Levine J, Colombel JF, Ferrara J. Acute graft-versus-host disease of the gut: considerations for the gastroenterologist. Nat Rev Gastroenterol Hepatol 2017; 14:711-726. [PMID: 28951581 PMCID: PMC6240460 DOI: 10.1038/nrgastro.2017.126] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Haematopoietic stem cell transplantation (HSCT) is central to the management of many haematological disorders. A frequent complication of HSCT is acute graft-versus-host disease (GVHD), a condition in which immune cells from the donor attack healthy recipient tissues. The gastrointestinal system is among the most common sites affected by acute GVHD, and severe manifestations of acute GVHD of the gut portends a poor prognosis in patients after HSCT. Acute GVHD of the gastrointestinal tract presents both diagnostic and therapeutic challenges. Although the clinical manifestations are nonspecific and overlap with those of infection and drug toxicity, diagnosis is ultimately based on clinical criteria. As reliable serum biomarkers have not yet been validated outside of clinical trials, endoscopic and histopathological evaluation continue to be utilized in diagnosis. Once a diagnosis of gastrointestinal acute GVHD is established, therapy with systemic corticosteroids is typically initiated, and non-responders can be treated with a wide range of second-line therapies. In addition to treating the underlying disease, the management of complications including profuse diarrhoea, severe malnutrition and gastrointestinal bleeding is paramount. In this Review, we discuss strategies for the diagnosis and management of acute GVHD of the gastrointestinal tract as they pertain to the practising gastroenterologist.
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Affiliation(s)
- Steven Naymagon
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | - Leonard Naymagon
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| | - Serre-Yu Wong
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | - Huaibin Mabel Ko
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai.,Lillian and Henry M. Stratton-Hans Popper Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, New York 10029, USA
| | - Anne Renteria
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| | - John Levine
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| | | | - James Ferrara
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
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75
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Pelletier JH, Nagaraj S, Gbadegesin R, Wigfall D, McGann KA, Foreman J. Neutropenic enterocolitis (typhlitis) in a pediatric renal transplant patient. A case report and review of the literature. Pediatr Transplant 2017; 21. [PMID: 28664544 DOI: 10.1111/petr.13022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 12/15/2022]
Abstract
NE (typhlitis) is a potentially life-threatening disease process characterized by bowel wall edema, ulceration, and hemorrhage in an immunosuppressed patient. We report a 15-year-old boy status post deceased donor renal transplantation who presented with fever, abdominal pain, and diarrhea. Laboratory studies revealed neutropenia 5 days prior to admission, and abdominal computed tomography revealed bowel wall thickening in the cecum consistent with NE. He was treated with piperacillin-tazobactam and gentamicin and recovered. To our knowledge, this is the first report of a case of NE in a pediatric kidney transplant recipient.
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Affiliation(s)
| | - Shashi Nagaraj
- Division of Pediatric Nephrology, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Rasheed Gbadegesin
- Division of Pediatric Nephrology, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Delbert Wigfall
- Division of Pediatric Nephrology, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Kathleen A McGann
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - John Foreman
- Division of Pediatric Nephrology, Department of Pediatrics, Duke University Health System, Durham, NC, USA
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76
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Ham JJ, Ordonez E, Wilkerson RG. Care of Acute Gastrointestinal Conditions in the Observation Unit. Emerg Med Clin North Am 2017; 35:571-587. [PMID: 28711125 DOI: 10.1016/j.emc.2017.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The Emergency Department Observation Unit (EDOU) provides a viable alternative to inpatient admission for the management of many acute gastrointestinal conditions with additional opportunities of reducing resource utilization and reducing radiation exposure. Using available evidence-based criteria to determine appropriate patient selection, evaluation, and treatment provides higher-quality medical care and improved patient satisfaction. Discussions of factors involved in creating an EDOU capable of caring for acute gastrointestinal conditions and clinical protocol examples of acute appendicitis, gastrointestinal hemorrhage, and acute pancreatitis provide a framework from which a successful EDOU can be built.
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Affiliation(s)
- Jason J Ham
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Spc 5301, Ann Arbor, MI 48109, USA.
| | - Edgar Ordonez
- Department of Emergency Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201-1559, USA
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77
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Florescu DF, Sandkovsky U, Kalil AC. Sepsis and Challenging Infections in the Immunosuppressed Patient in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:415-434. [PMID: 28687212 DOI: 10.1016/j.idc.2017.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2017, most intensive care units (ICUs) worldwide are admitting a growing population of immunosuppressed patients. The most common causes of pre-ICU immunosuppression are solid organ transplantation, hematopoietic stem cell transplantation, and infection due to human immunodeficiency virus. In this article, the authors review the most frequent infections that cause critical care illness in each of these 3 immunosuppressed patient populations.
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Affiliation(s)
- Diana F Florescu
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA
| | - Uriel Sandkovsky
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA
| | - Andre C Kalil
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA.
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Pugliese N, Salvatore P, Iula DV, Catania MR, Chiurazzi F, Della Pepa R, Cerchione C, Raimondo M, Giordano C, Simeone L, Caruso S, Pane F, Picardi M. Ultrasonography-driven combination antibiotic therapy with tigecycline significantly increases survival among patients with neutropenic enterocolitis following cytarabine-containing chemotherapy for the remission induction of acute myeloid leukemia. Cancer Med 2017; 6:1500-1511. [PMID: 28556623 PMCID: PMC5504336 DOI: 10.1002/cam4.1063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/10/2017] [Accepted: 03/04/2017] [Indexed: 12/27/2022] Open
Abstract
Neutropenic enterocolitis (NEC) is an abdominal infection reported primarily in patients with acute myeloid leukemia (AML) following chemotherapy, especially cytarabine, a notable efficacious cytotoxic agent for AML remission. Specific data regarding the impact of different cytarabine schedules and/or antibacterial regimens for NEC are sparse. The aim of the study was to identify the predictors of outcome within 30 days of NEC onset. NEC episodes were retrospectively pinpointed among 440 patients with newly diagnosed AML hospitalized in our Institution, over a 10‐year period, for receiving chemotherapy protocols with 100–6000 mg/m2 daily of cytarabine. Two subgroups, survivors versus nonsurvivors, were compared by using logistic regression analysis. NEC was documented in 100 of 420 (23.8%) analyzed patients: 42.5% had received high‐dose cytarabine, whereas 19% and 15% intermediate‐dose and standard‐dose cytarabine, respectively (P < 0.001). The 30‐day NEC attributable mortality rate was 23%. In univariate analysis, antileukemic protocols containing robust dosages of cytarabine were significantly associated with high mortality (P < 0.001); whereas, standard‐dose cytarabine and prompt initiation (at the ultrasonographic appearance of intestinal mural thickening) of NEC therapy with antibiotic combinations including tigecycline were significantly associated with low mortality. In multivariate analysis, high‐dose cytarabine‐containing chemotherapy was the independent predictor of poor outcome (odds ratio [OR]: 0.109; 95% confidence interval [CI]: 0.032–0.364; P < 0.001), whereas ultrasonography‐driven NEC therapy with antibiotic regimens including tigecycline was associated with a favorable outcome (OR: 13.161; 95% CI: 1.587–109.17; P = 0.017). Chemotherapy schedules with robust dosages of cytarabine for AML remission are associated with a high rate of NEC incidence and attributable. Vigorous antibacterial therapy, triggered off pathologic ultrasonographic findings, with drug combinations which have broad antimicrobial coverage and good gut penetration, specifically those also including tigecycline, may be effective in improving 30‐day survival rate after NEC onset.
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Affiliation(s)
- Novella Pugliese
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Paola Salvatore
- Molecular Medicine and Medical Biotechnology, Federico II University Medical School, Naples, Italy
| | - Dora Vita Iula
- Molecular Medicine and Medical Biotechnology, Federico II University Medical School, Naples, Italy
| | - Maria Rosaria Catania
- Molecular Medicine and Medical Biotechnology, Federico II University Medical School, Naples, Italy
| | - Federico Chiurazzi
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Roberta Della Pepa
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Claudio Cerchione
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Marta Raimondo
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Claudia Giordano
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Luigia Simeone
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Simona Caruso
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Fabrizio Pane
- Departments of Clinical Medicine and Surgery, Federico II University Medical School, Naples, Italy
| | - Marco Picardi
- Advanced Biomedical Sciences, Federico II University Medical School, Naples, Italy
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Lebon D, Biard L, Buyse S, Schnell D, Lengliné E, Roussel C, Gornet JM, Munoz-Bongrand N, Quéro L, Resche-Rigon M, Azoulay E, Canet E. Gastrointestinal emergencies in critically ill cancer patients. J Crit Care 2017; 40:69-75. [PMID: 28363097 DOI: 10.1016/j.jcrc.2017.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/09/2017] [Accepted: 03/20/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe gastrointestinal emergencies in cancer patients. METHODS All cancer patients admitted to the medical ICU of Saint-Louis Hospital for an acute abdominal syndrome during the study period (1997-2011) were included. RESULTS A total of 164 patients were included. The most common diagnoses were: neutropenic enterocolitis (NE) (n=54, 33%), infectious colitis and peritonitis (n=51, 31%), bowel infiltration by malignancy (n=14, 9%), and mucosal toxicity of chemotherapy (n=12, 7%). Microbiologically documented infections were reported in 82 patients (50%), including 12 fungal infections. Twenty-seven patients (16%) underwent urgent surgery. The hospital mortality rate was 35%. Five factors were independently associated with hospital mortality: the Simplified Acute Physiology Score II (SAPS II) score on day 1 (OR 1.03/SAPS II point, 95% CI 1.01 to 1.05), microbiological documentation (OR 0.27, 95% CI 0.11 to 0.64), neutropenia (OR 0.42, 95% CI 0.19 to 0.95), allogenic hematopoietic stem-cell transplantation (HSCT) (OR 5.13, 95% CI 1.71 to 15.4), and mechanical ventilation (OR 3.42, 95% CI 1.37 to 8.51). CONCLUSIONS Gastrointestinal emergencies in cancer patients are associated with significant mortality. Mortality correlated both with the severity of organ failure upon ICU admission and the underlying diagnosis. Interestingly, patients admitted to the ICU with neutropenia had better survival.
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Affiliation(s)
- Delphine Lebon
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Lucie Biard
- Biostatistics Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Sophie Buyse
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France
| | - David Schnell
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Etienne Lengliné
- Adult Hematology Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Camille Roussel
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Jean-Marc Gornet
- Department of Gastroenterology, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Nicolas Munoz-Bongrand
- Department of Digestive and Endocrine Surgery, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Laurent Quéro
- Radiation-Oncology Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Matthieu Resche-Rigon
- Biostatistics Department, Saint-Louis University Hospital, AP-HP, Paris, France; Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France; Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France.
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80
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Mokart D, Penalver M, Chow-Chine L, Ewald J, Sannini A, Brun JP, Bisbal M, Lelong B, Delpero JR, Faucher M, Turrini O. Surgical treatment of acute abdominal complications in hematology patients: outcomes and prognostic factors. Leuk Lymphoma 2017; 58:2395-2402. [DOI: 10.1080/10428194.2017.1296145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Djamel Mokart
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Marion Penalver
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Département de Chirurgie Oncologique, Institut Paoli-Calmettes, Marseille, France
| | - Antoine Sannini
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Jean Paul Brun
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Magali Bisbal
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Bernard Lelong
- Département de Chirurgie Oncologique, Institut Paoli-Calmettes, Marseille, France
| | - Jean Robert Delpero
- Département de Chirurgie Oncologique, Institut Paoli-Calmettes, Marseille, France
| | - Marion Faucher
- Réanimation Polyvalente et Département d’Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Turrini
- Département de Chirurgie Oncologique, Institut Paoli-Calmettes, Marseille, France
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Abstract
Solid tumors are much more common than hematologic malignancies. Although severe and prolonged neutropenia is uncommon, several factors increase the risk of infection in patients with solid tumors, and the presence of multiple risk factors in the same patient is not uncommon. These include obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces, and treatment-related factors such as chemotherapy, radiation, diagnostic and/or therapeutic surgical procedures, and the increasing use of medical devices such as various catheters, stents, and prostheses. Common sites of infection include the skin and skin structures (including surgical site infections), the bloodstream (including infections associated with central venous catheters), the lungs, the hepato-biliary and intestinal tracts, and the urinary tract, and include distinct clinical syndromes such as post-obstructive pneumonia, obstructive uropathy, and neutropenic enterocolitis. The epidemiology of most of these infections is changing with resistant organisms [MRSA, Pseudomonas aeruginosa, extended spectrum beta-lactamase (ESBL)-producing organisms] being isolated more often than in the past. Polymicrobial infections now predominate when deep tissue sites are involved. Conservative management of most of these infections (antibiotics, fluid and electrolyte replacement, bowel rest when needed) is generally effective, with surgical intervention being reserved for the drainage of deep abscesses, or to deal with complications such as intestinal obstruction or hemorrhage. Infected prostheses often need to be removed. Reactivation of certain viral infections (HBV, HCV, and occasionally CMV) has become an important issue, and screening, prevention and treatment strategies are being developed. Infection prevention, infection control, and antimicrobial stewardship are important strategies in the overall management of infections in patients with solid tumors. Occasionally, infections mimic solid tumors and cause diagnostic and therapeutic challenges.
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82
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Portugal R, Nucci M. Typhlitis (neutropenic enterocolitis) in patients with acute leukemia: a review. Expert Rev Hematol 2017; 10:169-174. [PMID: 28075196 DOI: 10.1080/17474086.2017.1280389] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Typhlitis is an abdominal complication of cancer chemotherapy, affecting mostly patients receiving intensive chemotherapeutic regimens with high potential to induce mucosal damage, such as patients with acute leukemia. Despite being relatively frequent, there are no randomized trials or high-quality cohort studies addressing important aspects of the diagnosis and management of the disease. Areas covered: In this review we discuss the gaps in the literature, acknowledging that the evidences for recommendations regarding the management of typhlitis are mostly expert opinion. We performed a computerized search of the MEDLINE database (PubMed version) for appropriate articles published from 1963 through July, 2016 in English language. Thereafter the reference lists of all identified studies were screened, reviewing the abstracts of all potentially pertinent articles for inclusion. Expert commentary: The diagnosis of typhlitis still relies on clinical and radiologic features consisting of fever, abdominal pain and thickness of a segment of the bowel wall, as seen by ultrasonography or CT scan. The treatment consists in antimicrobial therapy with a regimen that covers the most frequent pathogens, taking into consideration the local epidemiology. Other measures include bowel rest, and the use of G-CSF. Surgery is indicated only in selected situations.
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Affiliation(s)
- Rodrigo Portugal
- a Department of Internal Medicine , University Hospital, Universidade Federal do Rio de Janeiro , Rio de Janeiro , Brazil
| | - Marcio Nucci
- a Department of Internal Medicine , University Hospital, Universidade Federal do Rio de Janeiro , Rio de Janeiro , Brazil
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83
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Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol 2017; 23:42-47. [PMID: 28104979 PMCID: PMC5221285 DOI: 10.3748/wjg.v23.i1.42] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/18/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023] Open
Abstract
Neutropenic colitis is a severe condition usually affecting immunocompromised patients. Its exact pathogenesis is not completely understood. The main elements in disease onset appear to be intestinal mucosal injury together with neutropenia and the weakened immune system of the afflicted patients. These initial conditions lead to intestinal edema, engorged vessels, and a disrupted mucosal surface, which becomes more vulnerable to bacterial intramural invasion. Chemotherapeutic agents can cause direct mucosal injury (mucositis) or can predispose to distension and necrosis, thereby altering intestinal motility. This article aims to review current concepts regarding neutropenic colitis’ pathogenesis, diagnosis, and management.
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84
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Rothia mucilaginosa Bacteremia and Subsequent Typhlitis in a Patient With Acute Myeloid Leukemia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000458] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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85
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Gray EJ, Darvishzadeh A, Sharma A, Ganeshan D, Faria SC, Lall C. Cancer therapy-related complications in the bowel and mesentery: an imaging perspective. Abdom Radiol (NY) 2016; 41:2031-47. [PMID: 27277528 DOI: 10.1007/s00261-016-0799-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cancer therapy-induced complications in the bowel and mesentery are fairly common. It is important for clinicians to be aware of these complications and the agents most frequently implicated. Cancer therapy is rapidly evolving and often encompasses both classic cytotoxic drugs and newer molecular targeted agents. Drugs from both broad classes can have numerous adverse effects on the bowel and mesentery that can be detected on imaging. These adverse effects include ileus, various forms of enterocolitis, gastrointestinal perforation, pneumatosis intestinalis, secretory diarrhea, and sclerosing mesenteritis. These complications are diverse and range from relatively benign to life threatening. The management is also variable, but many of these conditions are easily controlled and reversed with supportive care and cessation of the particular cancer therapy. The objective of this pictorial essay is to demonstrate some of the more common cancer therapy-induced complications of the bowel and mesentery, with a focus on the radiographic findings.
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Affiliation(s)
- Eric J Gray
- Department of Radiological Sciences, University of California, Irvine School of Medicine, 101 The City Drive South, Orange, CA, 92868, USA.
| | - Ayeh Darvishzadeh
- Department of Radiological Sciences, University of California, Irvine School of Medicine, 101 The City Drive South, Orange, CA, 92868, USA
| | - Ankush Sharma
- Department of Internal Medicine, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Dhakshinamoorthy Ganeshan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Silvana C Faria
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chandana Lall
- Department of Radiological Sciences, University of California, Irvine School of Medicine, 101 The City Drive South, Orange, CA, 92868, USA
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86
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McKean J, Ronan-Bentle S. Abdominal Pain in the Immunocompromised Patient-Human Immunodeficiency Virus, Transplant, Cancer. Emerg Med Clin North Am 2016; 34:377-86. [PMID: 27133250 DOI: 10.1016/j.emc.2015.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patients with human immunodeficiency virus, those who are posttransplant, and those undergoing chemotherapy are populations who are immunocompromised and present to the emergency department with abdominal pain related to their disease processes, opportunistic infections, and complications of treatment. Emergency department practitioners must maintain vigilance, as the physical examination is often unreliable in these patients. Cross-sectional imaging and early treatment of symptoms with aggressive resuscitation is often required.
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Affiliation(s)
- Jonathan McKean
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0769, Cincinnati, OH 45267-0769, USA
| | - Sarah Ronan-Bentle
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0769, Cincinnati, OH 45267-0769, USA.
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88
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Abstract
Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.
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89
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Hamdeh S, Abdelrahman AAM, Elsallabi O, Pathak R, Giri S, Mosalpuria K, Bhatt VR. Clinical approach to diarrheal disorders in allogeneic hematopoietic stem cell transplant recipients. World J Hematol 2016; 5:23-30. [DOI: 10.5315/wjh.v5.i1.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/03/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Diarrhea is a common complication of allogeneic hematopoietic stem cell transplant (HSCT), with an average incidence of approximately 40%-50%. A wide variety of etiologies can contribute to diarrhea in HSCT patients, including medication-induced mucosal inflammation, infections, graft-vs-host disease and cord colitis syndrome in umbilical cord blood transplant. Clinical manifestations can vary from isolated diarrheal episodes, to other organ involvement including pneumonia or myocarditis, and rarely multiorgan failure. The approach for diagnosis of diarrheal disorders in HSCT patients depends on the most likely cause. Given the risk of life-threatening conditions, the development of clinically significant diarrhea requires prompt evaluation, supportive care and specific therapy, as indicated. Serious metabolic and nutritional disturbances can happen in HSCT patients, and may even lead to mortality. In this review, we aim to provide a practical approach to diagnosis and management of diarrhea in the post-transplant period.
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90
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La typhlite, une urgence à reconnaître…. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0579-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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91
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Gjeorgjievski M, Amin MB, Cappell MS. Characteristic clinical features of Aspergillus appendicitis: Case report and literature review. World J Gastroenterol 2015; 21:12713-12721. [PMID: 26640349 PMCID: PMC4658627 DOI: 10.3748/wjg.v21.i44.12713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/13/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
This work aims to facilitate diagnosing Aspergillus appendicitis, which can be missed clinically due to its rarity, by proposing a clinical pentad for Aspergillus appendicitis based on literature review and one new case. The currently reported case of pathologically-proven Aspergillus appendicitis was identified by computerized search of pathology database at William Beaumont Hospital, 1999-2014. Prior cases were identified by computerized literature search. Among 10980 pathology reports of pathologically-proven appendicitis, one case of Aspergillus appendicitis was identified (rate = 0.01%). A young boy with profound neutropenia, recent chemotherapy, and acute myelogenous leukemia presented with right lower quadrant pain, pyrexia, and generalized malaise. Abdominal computed tomography scan showed a thickened appendiceal wall and periappendiceal inflammation, suggesting appendicitis. Emergent laparotomy showed an inflamed, thickened appendix, which was resected. The patient did poorly postoperatively with low-grade-fevers while receiving antibacterial therapy, but rapidly improved after initiating amphotericin therapy. Microscopic examination of a silver stain of the appendectomy specimen revealed fungi with characteristic Aspergillus morphology, findings confirmed by immunohistochemistry. Primary Aspergillus appendicitis is exceptionally rare, with only 3 previously reported cases. All three cases presented with (1)-neutropenia, (2)-recent chemotherapy, (3)-acute leukemia, and (4)-suspected appendicitis; (5)-the two prior cases initially treated with antibacterial therapy, fared poorly before instituting anti-Aspergillus therapy. The current patient satisfied all these five criteria. Based on these four cases, a clinical pentad is proposed for Aspergillus appendicitis: clinically-suspected appendicitis, neutropenia, recent chemotherapy, acute leukemia, and poor clinical response if treated solely by antibacterial/anti-candidial therapy. Patients presenting with this proposed pentad may benefit from testing for Aspergillus infection by silver-stains/immunohistochemistry and considering empirical anti-Aspergillus therapy pending a tissue diagnosis.
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92
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Sullivan PS, Moreno C, Shaib WL. Management of anorectal and intra-abdominal infections in the neutropenic cancer patient. Curr Probl Cancer 2015; 39:274-86. [PMID: 26566580 DOI: 10.1016/j.currproblcancer.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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93
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Hadchiti MT, Abdalkader M, Rached L, Mahfoud D, Khoury G, Ghanem H. Disseminated Intra-Abdominal Aspergilloma With Abdominal Wall Invasion in a Patient With Acute Myeloid Leukemia: A Case Report. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15 Suppl:S94-7. [PMID: 26297288 DOI: 10.1016/j.clml.2014.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/31/2014] [Accepted: 12/31/2014] [Indexed: 01/03/2023]
Affiliation(s)
| | | | - Linda Rached
- Division of General Surgery, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon
| | - Daniel Mahfoud
- Division of Radiology, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon
| | - Georges Khoury
- Division of General Surgery, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon
| | - Hady Ghanem
- Division of Hematology-Oncology, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon.
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94
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Mutoh Y, Hirai R, Tanimura A, Matono T, Morino E, Kutsuna S, Nagamatsu M, Ohmagari N, Hagiwara S. Osteomyelitis due to Clostridium innocuum in a patient with acute lymphoblastic leukemia: case report and literature review. SPRINGERPLUS 2015; 4:385. [PMID: 26240783 PMCID: PMC4518021 DOI: 10.1186/s40064-015-1176-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 07/21/2015] [Indexed: 01/03/2023]
Abstract
Introduction Clostridium innocuum is an anaerobic Gram-positive bacterium, unable to produce toxins and rarely causes infections. We report the first case of C. innocuum osteomyelitis and bacteremia in a patient with acute lymphoblastic leukemia (ALL). Findings were compared with previously reported cases of C. innocuum infections in immunocompromised patients, e.g., patients with acquired immune deficiency syndrome, leukemia, and organ transplantation. Case description A 32-year-old Japanese male was admitted for persistent low-grade fever and purpura lasting for 1 month. Complete blood counts and cytogenetic analysis identified Ph1-positive ALL, which was successfully treated using chemotherapy. However, the patient developed high fever and lumbar pain during complete remission. Fluorodeoxyglucose-positron emission tomography and computed tomography demonstrated osteomyelitis. C. innocuum was identified as the causative agent and the patient was successfully treated using antibiotic therapy. Discussion and evaluation We performed a literature review revealing a number of common aspects to the clinical presentation of C. innocuum infection and an association with various comorbidities. Further, we highlight the most efficient diagnostic and treatment strategies for C. innocuum osteomyelitis. Conclusions Clostridium innocuum can be a causative pathogen of osteomyelitis and bacteremia in immunocompromised patients. Electronic supplementary material The online version of this article (doi:10.1186/s40064-015-1176-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yoshikazu Mutoh
- Division of Hematology, Department of Internal Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan ; Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Risen Hirai
- Division of Hematology, Department of Internal Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Akira Tanimura
- Division of Hematology, Department of Internal Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Takashi Matono
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Eriko Morino
- Department of Respiratory Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Kutsuna
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Maki Nagamatsu
- Department of Infectious Diseases, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Shotaro Hagiwara
- Division of Hematology, Department of Internal Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
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96
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Koinis F, Nintos G, Georgoulias V, Kotsakis A. Therapeutic strategies for chemotherapy-induced neutropenia in patients with solid tumors. Expert Opin Pharmacother 2015; 16:1505-19. [DOI: 10.1517/14656566.2015.1055248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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97
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Kerhuel L, Amorim S, Azoulay E, Thiéblemont C, Canet E. Clinical features of life-threatening complications following autologous stem cell transplantation in patients with lymphoma. Leuk Lymphoma 2015; 56:3090-5. [DOI: 10.3109/10428194.2015.1034700] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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98
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Bayramoglu A, Saritemur M, Citirik F, Emet M, Cakir Z. A rare cause of acute abdomen for which broad-spectrum antibiotics should be initiated in emergency service: typhlitis. Am J Emerg Med 2015; 33:738.e1-3. [DOI: 10.1016/j.ajem.2014.10.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 10/18/2014] [Accepted: 10/21/2014] [Indexed: 01/03/2023] Open
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99
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Zafrani L, Azoulay E. How to treat severe infections in critically ill neutropenic patients? BMC Infect Dis 2014; 14:512. [PMID: 25431154 PMCID: PMC4289060 DOI: 10.1186/1471-2334-14-512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 09/09/2014] [Indexed: 12/30/2022] Open
Abstract
Severe infections in neutropenic patient often progress rapidly leading to life-threatening organ dysfunction requiring admission to the Intensive Care Unit. Management strategies include early adequate appropriate empirical antimicrobial, early admission to ICU to avoid any delay in the diagnostic and therapeutic management of organ dysfunction. This review discusses the main clinical situations encountered in critically ill neutropenic patients. Specific diagnostic and therapeutic approaches have been proposed for acute respiratory failure, shock, neutropenic enterocolitis, catheter-related infections, cellulitis and primary bacteriemia. Non anti-infectious agents and recent advances will also be discussed. At present, most of large-scale studies and recommendations in neutropenic patients stem from hematological patients and will need further validation in ICU patients.
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Affiliation(s)
| | - Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (Grrr-OH), Paris, France.
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Risk factors associated with Clostridium difficile infection in adult oncology patients. Support Care Cancer 2014; 23:1569-77. [DOI: 10.1007/s00520-014-2506-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023]
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