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Benedetti E, Traverso G, Pucci G, Morganti R, Bramanti E, Lippolis P, Susini MC, Mazzantini E, Giubbolini R, Mavilia F, Capochiani E, Neri E, Arena C, Cerri F, De Simone L, Valentini K, Stella SM, Ricchiuto V, Bruno B, Galimberti S. Impact of different chemotherapy regimens on intestinal mucosal injury assessed with bedside ultrasound: a study in 213 AML patients. Front Oncol 2023; 13:1272072. [PMID: 38023169 PMCID: PMC10646482 DOI: 10.3389/fonc.2023.1272072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Neutropenic enterocolitis (NEC) is a life-threatening complication reported in patients with acute myeloid leukemia (AML) following chemotherapy (CHT). Intensive induction and consolidation CHT may damage intestinal mucosa leading to a NEC episode (NECe). NEC reported mortality may be up to 30-60%. Early US-guided bed-side diagnosis and prompt treatment may substantially improve the survival. An emerging worldwide concern is the intestinal colonization by multi-drug-resistant bacteria especially when patients are exposed to chemotherapy regimens potentially correlated to mucosal damage. Methods In our study we prospectively enrolled all AML patients admitted in our leukemia unit to receive intensive induction and consolidation chemotherapy and experiencing chemotherapy-induced-neutropenia (CHTN). Results and discussion Overall, we enrolled N=213 patients from 2007 to March 2023. We recorded N=465 CHTN, and N=42 NECe (9.0% incidence). The aim of our study was to assess which chemotherapy regimens are more associated with NEC. We found that ALM1310, followed by 7 + 3 (daunorubicin), 7 + 3 (idarubicin), 5 + 3 + 3 (cytarabine, etoposide, idarubicin), and AML1310 (consolidation) were associated with a statistically higher incidence of NEC. We did not detect NEC episodes in patients treated with CPX-351, 5 + 2 (cytarabine, idarubicine), and high-dose cytarabine. Thus, we found that cytarabine could determine mucosal damage when associated with an anthracycline but not if delivered either alone or as dual-drug liposomal encapsulation of daunorubicin/cytarabine. We also describe NEC mortality, symptoms at diagnosis, intestinal sites involvement, and prognostic significance of bowel wall thickening.
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Affiliation(s)
- Edoardo Benedetti
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ginevra Traverso
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giulia Pucci
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Morganti
- Section of Statistics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Emilia Bramanti
- Institute of Chemistry of Organo Metallic Compounds (ICCOM), Consiglio Nazionale delle Ricerche (CNR), Pisa, Italy
| | - Piero Lippolis
- General and Peritoneal Surgery Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maria Chiara Susini
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Elisa Mazzantini
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Fabrizio Mavilia
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Emanuele Neri
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Chiara Arena
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesca Cerri
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Luigi De Simone
- Anesthesia and Maternal-Infantile Resuscitation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Katia Valentini
- Anesthesia and Maternal-Infantile Resuscitation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Vittorio Ricchiuto
- Dipartimento di Tecnologie Sanitarie ESTAR, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Sara Galimberti
- Hematology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Amanati A, Zekavat OR, Foroutan H, Azh O, Tadayon A, Monabati A, Anbardar MH, Bozorgi H. Case reports of invasive mucormycosis associated neutropenic enterocolitis in leukemic children: diagnostic and treatment challenges and review of literature. BMC Infect Dis 2021; 21:1268. [PMID: 34930171 PMCID: PMC8686658 DOI: 10.1186/s12879-021-06957-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/07/2021] [Indexed: 12/30/2022] Open
Abstract
Background Bacterial enterocolitis is one of the most common neutropenic fever complications during intensive chemotherapy. Despite aggressive antibacterial treatments, this complication usually imposes high morbidity and mortality in cancer patients. Management of bacterial neutropenic enterocolitis are well known; however, management of fungal neutropenic enterocolitis may be more challenging and needs to be investigated. Prompt diagnosis and treatment may be life-saving, especially in patients at risk of mucormycosis-associated neutropenic enterocolitis. Case presentation We report two mucormycosis-associated neutropenic enterocolitis cases in pediatric leukemic patients receiving salvage chemotherapy for disease relapse. Both patients' clinical signs and symptoms differ from classical bacterial neutropenic enterocolitis. They were empirically treated as bacterial neutropenic enterocolitis with anti-gram-negative combination therapy. Despite broad-spectrum antimicrobial treatment, no clinical improvement was achieved, and both of them were complicated with severe abdominal pain necessitating surgical intervention. Mucormycosis is diagnosed by immunohistopathologic examination in multiple intraoperative intestinal tissue biopsies. Both patients died despite antifungal treatment with liposomal amphotericin-B and surgical intervention. Conclusion Mucormycosis-associated neutropenic enterocolitis is one of the most unfavorable and untreatable side effects of salvage chemotherapy in leukemic children with disease relapse. This report could be of considerable insight to the clinicians and scientists who counter the enigma of fungal infections during febrile neutropenia and help to understand better diagnosis and management.
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Early Diagnosis of Neutropenic Enterocolitis by Bedside Ultrasound in Hematological Malignancies: A Prospective Study. J Clin Med 2021; 10:jcm10184277. [PMID: 34575387 PMCID: PMC8468879 DOI: 10.3390/jcm10184277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Neutropenic enterocolitis (NEC) is a life-threatening complication following chemotherapy with high mortality rates. Early diagnosis is crucial to improve outcomes. We designed a large prospective study employing bedside ultrasonography (US) as a novel approach to allow early diagnosis and prompt treatment to reduce mortality. (2) Methods: NEC was defined as US or computed tomography (CT)-proven bowel wall thickness ≥ 4 mm at the onset of at least one of the following symptoms: fever and/or abdominal pain and/or diarrhea during neutropenia. From 2007 to 2018, 1754 consecutive patients underwent baseline bedside US that was invariably repeated within 12 h from the onset of symptom(s) suggestive of NEC. (3) Results: Overall, 117 episodes of NEC were observed, and overall mortality was 9.4%. Bowel wall thickening was invariably absent in the negative control group. Abdominal pain associated with one or more symptoms correlated with the highest relative risk (17.33), sensitivity (89.7%), specificity (100%), and accuracy (96.2%) for diagnosis. The combination of abdominal pain and fever at onset significantly correlated with worse survival (p < 0.0001, OR 13.85). BWT (p = 0.046), type of therapy (p = 0.049) and blood culture positivity (p = 0.003) correlated with worse survival. (4) Conclusions: Bedside ultrasound is a non-invasive and radiation free imaging technique for early diagnosis of NEC and its prompt treatment significantly reduced mortality.
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Nathan S, Ustun C. Complications of Stem Cell Transplantation that Affect Infections in Stem Cell Transplant Recipients, with Analogies to Patients with Hematologic Malignancies. Infect Dis Clin North Am 2019; 33:331-359. [PMID: 30940464 DOI: 10.1016/j.idc.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article discusses the complications of hematopoietic stem cell transplantion (HSCT) that affect infections in HSCT recipients, with analogies to patients with hematologic malignancies. Mucositis, with mucosal barrier disruption, is common and increases the risk of gram-positive and anaerobic bacterial, and fungal infections, and can evolve to typhlitis. Engraftment syndrome; graft-versus-host disease, hepatic sinusoidal obstruction syndrome; and posterior reversible encephalopathy syndrome can affect the infectious potential either directly from organ dysfunction or indirectly from specific treatment. Pulmonary infections can predispose to life threatening complications including diffuse alveolar hemorrhage, idiopathic pulmonary syndrome, bronchiolitis obliterans syndrome, and bronchiolitis obliterans with organizing pneumonia.
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Affiliation(s)
- Sunita Nathan
- Section of Bone Marrow Transplant and Cellular Therapy, Division of Hematology, Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL 60612, USA
| | - Celalettin Ustun
- Section of Bone Marrow Transplant and Cellular Therapy, Division of Hematology, Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL 60612, USA.
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Tamburrini S, Setola FR, Belfiore MP, Saturnino PP, Della Casa MG, Sarti G, Abete R, Marano I. Ultrasound diagnosis of typhlitis. J Ultrasound 2018; 22:103-106. [PMID: 30367357 DOI: 10.1007/s40477-018-0333-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/18/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Typhlitis, also known as neutropenic colitis, is a rare inflammatory condition and a potentially life-threatening disease process that typically involves the cecum. Delay in diagnosis may lead to a fatal prognosis with a death rate of 21-48%. Ultrasound evaluation of right lower quadrant may lead to an accurate and rapid diagnosis. METHODS We describe the case of a 59-year-old female with advanced Churg-Strauss syndrome treated with cyclophosphamide, with acute right lower quadrant pain. RESULTS Ultrasound was the first diagnostic step in the diagnosis of typhlitis. Sonographic findings were comparable to CT imaging. CONCLUSIONS Bowel bedside ultrasound evaluation in emergency settings may lead to a prompt and definitive diagnosis. Although CT is considered the gold standard in the diagnosis and staging of neutropenic colitis, ultrasound was able to identify the pathology accurately. Ultrasound findings of typhlitis are highly characteristic, showing circumferential wall thickening with predominant submucosa.
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Affiliation(s)
- Stefania Tamburrini
- Department of Radiology-Ospedale del Mare-ASL NA1 Centro-Napoli, Naples, Italy.
| | | | | | | | | | - Giuseppe Sarti
- Department of Radiology-Ospedale dei Pellegrini-ASL NA1 Centro-Napoli, Naples, Italy
| | - Roberta Abete
- Department of Surgery-Ospedale del Mare-ASL NA1 Centro, Naples, Italy
| | - Ines Marano
- Department of Radiology-Ospedale del Mare-ASL NA1 Centro-Napoli, Naples, Italy
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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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Bordbar M, Kamali K, Basiratnia M, Fourotan H. Enterovesical fistula as a result of neutropenic enterocolitis in a pediatric patient with acute leukemia. Pediatr Blood Cancer 2017; 64. [PMID: 27696712 DOI: 10.1002/pbc.26283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/28/2016] [Accepted: 08/30/2016] [Indexed: 11/10/2022]
Affiliation(s)
| | - Karmella Kamali
- Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mitra Basiratnia
- Nephrology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Fourotan
- Pediatric Surgery Wards, Shiraz University of Medical Sciences, Shiraz, Iran
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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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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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Bhardwaj AS, Navada SC. Management of Chemotherapy-Induced Neutropenic Fever. Hosp Pract (1995) 2015; 41:96-108. [PMID: 23466972 DOI: 10.3810/hp.2013.02.1015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Junpaparp P, Buppajarntham S, Madueno FV, Varadi G. Concomitant typhlitis and Clostridium difficile colitis developed after first R-CHOP chemotherapy in a non-Hodgkin lymphoma patient. BMJ Case Rep 2013; 2013:bcr-2013-008894. [PMID: 23598937 DOI: 10.1136/bcr-2013-008894] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Typhlitis or neutropenic enterocolitis (NEC) is a life-threatening condition that occurs in neutropenic patients. Early recognition is crucial owing to high death rate. We present a case of a 54-year-old man, diagnosed with non-Hodgkin lymphoma who received a first cycle of rituximab, cyclophosphamide, hydroxydaunorubicin (doxorubicin), oncovin (vincristine), prednisolone (R-CHOP) chemotherapy 10 days prior presenting. He developed fever, mucositis, watery diarrhoea and right lower quadrant pain with rebound tenderness. He also had neutropenia, with an absolute neutrophil count of zero. CT abdomen confirmed the diagnosis of typhlitis, demonstrating characteristic terminal ileum, caecal and right-sided colon involvement. Moreover, stool PCR was also positive for toxigenic Clostridium difficile. Therefore, the patient was diagnosed with concomitant typhlitis and C difficile-associated diarrhoea (CDAD). He was empirically treated with intravenous cefepime, intravenous metronidazole and oral vancomycin. His symptoms resolved in 10 days. This case illustrated a successful medical treatment of typhlitis in concomitance with CDAD.
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Affiliation(s)
- Parichart Junpaparp
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.
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Li K, Zheng S, Dong K, Gao Y, Wang H, Liu G, Gao J, Xiao X. Diagnosis and outcome of neutropenic enterocolitis: experience in a single tertiary pediatric surgical center in China. Pediatr Surg Int 2011; 27:1191-5. [PMID: 21667116 DOI: 10.1007/s00383-011-2938-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2011] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE Neutropenic enterocolitis (NE) is clinically defined by the triad of neutropenia, abdominal pain and fever. This retrospective study is to review 24 cases of NE in a single Chinese tertiary center, to elucidate clinical feature, treatments and outcome for this dangerous gastrointestinal complication of neutropenia. PATIENTS AND METHODS The medical records of pediatric patients who were diagnosed with neutropenic enterocolitis from 2000 to 2009 were reviewed. RESULTS Of 24 cases, the ratio of male to female was 2:1, the mean age was 7.2 years. There were eight cases of acute lymphocytic leukemia, eight cases of acute non-lymphocytic leukemia, four cases of non-Hodgkin's lymphoma, one case of severe aplastic anemia, one case of neuroblastoma and two cases of simple neutropenia without underlying cause. The hematologic malignancy was significantly associated with the occurrence of NE (OR = 19.4). Seventeen cases developed NE during anticancer chemotherapy (chemo group), four cases presented with leukemia and one case presented with aplastic anemia before the initiation of chemotherapy and their presenting event leading to diagnosis. Two cases simply presented with NE without definitive reasons (no chemo group). All the patients had the typical clinical presentation, six cases had disseminated peritonitis, toxic shock, and assisted ventilations were necessary in three of these six cases. CT or ultrasound demonstrated bowel wall thickness, paucity of air in the cecum and/or right colon, pneumatosis or pneumoperitoneum. There was no difference in the nadir neutrophil count in patients, who received chemotherapy versus those who did not (P = 0.001), but the recovering time from NE in chemo group (9.3 ± 1.9) was shorter than non-chemo group (10.7 ± 5.3, P = 0.034). Sixteen (88.8%) cases have been successfully managed medically, using aggressive hemodynamic support, bowel rest, and broad-spectrum antibiotic therapy with surgical intervention reversed only for the more severe six cases (25%). Two cases died. CONCLUSION NE is a life-threatening gastrointestinal complication of neutropenia. Physicians might remain vigilant and consider NE in any neutropenic patient rather than only in oncologic patients. It has typical clinical presentation and CT can provide clear delineation for diagnosis. Early recognition and progressed management have reduced mortality. Most children with NE may be treated without surgery with favorable outcome.
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Affiliation(s)
- Kai Li
- Children's Hospital of Fudan University, Shanghai, People's Republic of China
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Agrawal AK, Saini N, Gildengorin G, Feusner JH. Is routine computed tomographic scanning justified in the first week of persistent febrile neutropenia in children with malignancies? Pediatr Blood Cancer 2011; 57:620-4. [PMID: 21265012 DOI: 10.1002/pbc.22974] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 11/18/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prolonged febrile neutropenia (FN) remains a common problem in pediatric oncology and often leads to empiric computed tomography (CT) of the sinuses, chest, abdomen, and pelvis. Little evidence is available as to the diagnostic utility of CT in this setting. PROCEDURE We performed a retrospective review of all oncology patients admitted to the hospital from January 2004 through December 2008 for FN who had daily fevers with neutropenia for 4 or more consecutive days prompting CT evaluation. Eligible patient charts were reviewed for symptomatology prior to imaging as well as antibiotic and antifungal regimens throughout therapy. RESULTS Fifty-two patients had 68 unique episodes of prolonged FN that resulted in CT imaging. Positive findings occurred in 18%, 12%, and 25% of initial chest, abdomen, and sinus CTs, respectively. There were no positive findings on initial pelvic CT. Only two of the initial positive CT scans led to a change in management (6.5% of positive scans, 0.8% of all initial scans). These were both scans of the chest. All patients with concern for occult fungal infection had findings on chest CT. Patients with clinically important infections had no statistical difference in days of fever or neutropenia or type of underlying malignancy compared with those without infection. Clinical symptomatology was most helpful for typhlitis. CONCLUSIONS Treatment alteration rarely results from empiric CT imaging in the early days of prolonged FN. We therefore recommend limiting initial empiric CT imaging to the chest only in patients without localizing signs or symptoms and prolonged FN.
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Affiliation(s)
- Anurag K Agrawal
- Children's Hospital and Research Center, Oakland, California 94609, USA.
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Weatherhead JE, Tweardy DJ. Lethal human neutropenic entercolitis caused by Clostridium chauvoei in the United States: tip of the iceberg? J Infect 2011; 64:225-7. [PMID: 21945880 DOI: 10.1016/j.jinf.2011.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 09/03/2011] [Accepted: 09/13/2011] [Indexed: 11/25/2022]
Abstract
The patient is a 44-year-old woman with metastatic grade 3 intra-ductal carcinoma of the breast who was started on palliative chemotherapy (docetaxel) 10 days prior to admission and presented to the emergency center complaining of diffuse abdominal pain and generalized weakness. CT abdomen showed diffuse bowel wall thickening from the cecum to the transverse colon with free fluid in the pelvis. The patient was neutropenic on admission (absolute neutrophil count of 600 cells/μl). She received antibiotics for 21 days for neutropenic enterocolitis. Blood culture isolate from admission was sent for 16s rRNA gene sequencing, which identified Clostridium chauvoei. While C. chauvoei has a long history of veterinary importance, this is the first documented case of infection caused by C. chauvoei in a human in the United States. C. chauvoei has a close phylogenetic relationship with C. septicum making the two species difficult to differentiate using conventional microbiologic methods. With increased use of more reliable detection methods the actual prevalence of C. chauvoei causing human disease may be higher than currently recognized.
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Affiliation(s)
- Jill E Weatherhead
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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