Neutropenic enterocolitis: a rare presenting complication of acute leukemia

Neutropenic Enterocolitis: New Insights Into a Deadly Entity

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.

Systematic review of case reports concerning adults suffering from neutropenic enterocolitis

INTRODUCTION

Neutropenic enterocolitis (NEC) is a well recognised clinical-pathological and life-threatening complication in patients suffering from several conditions, including solid and haematological malignancies or aplastic anaemia.

OBJECTIVE

This review was aimed at evaluating overall NEC mortality rate, describing clinical diagnostic findings and therapeutical interventions reported in the literature and generating a hypothesis regarding factors influencing mortality and surgical intervention.

MATERIALS AND METHODS

An advanced search was made in Medline, Embase, Lilacs and Google. Additional strategies included manual search of specific journals. Reports were considered if they described case definition, inclusion and exclusion criteria.

RESULTS

275 cases were selected; 109 were from individual data and 40 from grouped data. Comparing data between case reports and case series revealed no significant differences related to mortality, surgical intervention, sex or age. Higher mortality (chi2 = 7.51 p = 0.006) was found in women (50%) compared to men (28%). No significant difference was found between antibiotic combinations and mortality (chi(2) = 12.85 df 13 p = 0.45). Mortality (chi2 = 3.89 df 1, p = 0.049), surgical intervention (chi2 = 7.64 df 1, p = 0.006) and duration of diarrhoea (chi2 = 4.71 df 1, p = 0.043) were significantly different in 26.4% of individuals using antifungal agents; death occurred in 81% of patients! who did not receive such medication compared to 19% individuals reported as being treated with antifungal agents.

CONCLUSION

The current evidence suggests that antifungal agents should be used early in patients suffering from NEC. However, this hypothesis must be evaluated in multi-centric, randomised controlled trials.

Surgical interventions in patients with hematologic malignancies

While surgery is not a part of treatment of hematological malignancies a significant number of patients suffering from such diseases need to undergo surgical interventions. These may comprise of very minor procedures such port implantation, however, already the indication for appendicectomy could be a difficult scenario being influenced by the underlying disease and side effects of the treatment. Often septic foci need to be cleared prior to start of systemic treatment. Out of the really major problems, the surgical resection of aspergillomas represent a demanding task accompanied by significant morbidity and mortality. Emergency situations sometimes are induced by treatment such as necrotizing enterocolitis but sometimes are mimicked by drug-induced abdominal symptoms. An experienced team of surgical and medical oncologists is required for successful management. As the number of long-term surviving patients increases, secondary problems as aseptic bone necrosis need to be addressed and adequately handled. Even at this stage it might be difficult to assess the patients risk for open-heart surgery adequately. This group of patients if scheduled for any operative intervention needs to undergo a very careful selection process and perfect perioperative management to make sure that the result of surgery are excellent and do not compromise further medical treatment of the underlying disease.

Intestinal pseudo-obstruction caused by diltiazem in a neutropenic patient

OBJECTIVE

To describe a case of diltiazem-induced intestinal pseudo-obstruction in a neutropenic patient.

CASE SUMMARY

A 74-year-old male with newly diagnosed acute myelogenous leukemia developed atrial fibrillation on day 12 of induction chemotherapy. He was initially treated with diltiazem 5 mg intravenously every 5-10 minutes for 5 doses and an amiodarone 150-mg loading dose intravenously. Diltiazem 30 mg orally 4 times daily and amiodarone continuous infusion were started thereafter. Amiodarone therapy was discontinued after one day due to an untoward adverse effect. The diltiazem dose was then escalated. By day 14, the patient was receiving diltiazem 120 mg orally 4 times daily. On day 15, he developed increasing abdominal distention with hyperactive bowel sounds. On day 16, a radiographic examination showed multiple dilated loops of both the small and large bowel representing possible intestinal pseudo-obstruction; diltiazem was discontinued that day. Starting on day 18, the patient showed recovery of intestinal pseudo-obstruction without intervention. No further GI complications developed during his remaining hospital course.

DISCUSSION

Intestinal pseudo-obstruction is usually associated with underlying medical conditions such as trauma, infection, cardiac disease, and after surgery. Medications rarely cause such a condition. Detailed examination of the patient's record indicated neither infection nor other medications contributed to the development of intestinal pseudo-obstruction. Additionally, a radiographic examination ruled out neutropenic enterocolitis, a common gastrointestinal complication in neutropenic patients. Use of the Naranjo probability scale indicated a probable relationship between pseudo-obstruction and diltiazem in this patient.

CONCLUSIONS

Although calcium-channel blockers rarely cause intestinal pseudo-obstruction, clinicians must be aware of this serious but reversible adverse effect.

Neutropenic enterocolitis in adults: systematic analysis of evidence quality

OBJECTIVE

Neutropenic enterocolitis is a life-threatening complication occurring most frequently after intensive chemotherapy in acute leukaemias. The literature is heterogeneous and a systematic review is lacking.

METHODS

Following a systematic search we categorised all relevant reports according to their quality and extracted evidence to answer the questions: Which diagnostic criteria are appropriate? What is the incidence of neutropenic enterocolitis? Are there good quality studies supporting specific interventions: Which empiric antimicrobial therapy is recommendable? Is neutropenic enterocolitis without surgical emergency complications an indication for bowel resection?

RESULTS

We found and analysed 145 articles of these reports: 64 were reports of single cases, 30 papers reported of two or three cases, 13 were narrative reviews, 34 were retrospective case series of more than three cases and four were prospective diagnostic studies. There were no prospective trials or case control studies on the therapy of neutropenic enterocolitis. There was no consensus on diagnostic criteria. We discuss the difficulty to define diagnostic criteria without having a disease definition. Histology is mostly not available in the living patients. We suggest applying a combination of clinical and radiological criteria: fever, abdominal pain and any bowel wall thickening >4 mm detected by ultrasonography (US) or computed tomography. We calculated a pooled incidence rate from 21 studies of 5.3% (266/5058; 95% CI: 4.7%-5.9%) in patients hospitalised for haematological malignancies, for high-dose chemotherapy in solid tumours or for aplastic anaemia.

CONCLUSIONS

This systematic review provides diagnostic criteria for neutropenic enterocolitis, presents a quantitative synthesis on its incidence and discusses its treatment recommendations. Prospective studies are clearly warranted.

Neutropenic enterocolitis in adults: case series and review of the literature

Necrotizing enterocolitis in adults is a rare disease and, in the past, has been associated with nearly uniform mortality. In recent years, necrotizing enterocolitis, now termed neutropenic enterocolitis, in adults has become more prevalent as a complication of aggressive systemic chemotherapy. In this report, we discuss two cases of neutropenic enterocolitis secondary to the administration of systemic chemotherapy in adult cancer patients: one with lung carcinoma, the other with leukemia. Both patients were successfully treated with early surgical intervention for resection of all necrotizing enteric lesions, and subsequent aggressive critical care support. Our experience suggests that early surgical intervention in adult patients with intestinal necrosis due to chemotherapy is essential to avoid mortality from this condition. Given the widespread, aggressive use of systemic chemotherapy in the neoadjuvant setting, patients at risk for this potentially lethal complication of neutropenic enterocolitis are increasingly common.

Neutropenic enterocolitis as a presenting complication of acute lymphoblastic leukemia: an unusual case marked by delayed perforation of the descending colon

Neutropenic enterocolitis (NE) is a life-threatening complication most commonly seen in patients receiving intensive chemotherapy for acute leukemia. The condition usually affects the terminal ileum, cecum, or ascending colon. In rare instances, NE may occur before the initiation of chemotherapy or involve more distal bowel. The authors report the case of a 2-year-old girl who had NE affecting the descending colon as a presenting complication of acute lymphoblastic leukemia. Despite aggressive medical interventions, including granulocyte infusions, she had a delayed bowel perforation that was managed successfully with surgery. This case highlights the challenges of treating patients who have NE as an initial manifestation of acute leukemia.

Neutropenic enterocolitis

Neutropenic enterocolitis is an acute syndrome characterized by cecal and ascending colon inflammation that may progress to necrosis and perforation. It is most often associated with leukemia but has also been described in patients with solid tumors, multiple myeloma, aplastic anemia, AIDS, and cyclic neutropenia. Medical management usually suffices, but surgical intervention may be required.

Acute leukaemia masquerading as acute abdomen

This article reports three patients with acute leukaemia who presented with acute abdomen as the first manifestation of the disease. Leukaemic infiltrates of the bowel and appendix may have caused the abdominal symptoms in these patients. Acute leukaemia should be included in the differential diagnosis of severe abdominal pain associated with an abnormal blood count. This report highlights the importance of early diagnosis of acute leukaemia as initiation of cytotoxic chemotherapy results in prompt resolution of the abdominal catastrophe and obviates the need for surgery.