Risk factors for typhlitis in pediatric patients with cancer

Neutropenic Enterocolitis Following Autologous Stem Cell Transplantation: A Compelling Clinical Case Report Written With the Assistance of ChatGPT

Neutropenic enterocolitis (NE) is a rare and life-threatening condition that typically occurs in patients with hematologic malignancies undergoing intensive chemotherapy, radiation therapy, or bone marrow transplant regimens, predisposing them to profound neutropenia. NE can have a nonspecific clinical presentation and mimic other gastrointestinal disorders such as appendicitis, diverticulitis, or inflammatory bowel disease but is associated with very high morbidity and mortality if not diagnosed and treated promptly. We present the case of a middle-aged female with a recent diagnosis of follicular lymphoma who developed neutropenic enterocolitis after undergoing induction chemotherapy for an autologous stem cell transplant (ASCT). In this article, we provide a literature review of neutropenic enterocolitis and highlight the importance of a prompt diagnosis and management, given its high mortality rate.

Outcome and Determinants of Neutropenic Enterocolitis in Pediatric Cancer Patients

BACKGROUND

Neutropenic enterocolitis (NEC) is a dreaded complication of chemotherapy. There is scant literature regarding incidence, clinical features, and determinants. The understanding of gut dysbiosis in NEC and pediatric cancer is evolving.

METHODS

Pediatric cancer patients with neutropenia and gastrointestinal symptoms were evaluated for NEC with contrast-enhanced computed tomography abdomen. Clinical, imaging, and laboratory features were analyzed. Fecal samples were analyzed for fecal calprotectin by sandwich enzyme-linked immunoassay and gut microbiota by conventional culture and compared with healthy controls and children without NEC.

RESULTS

NEC was diagnosed in 44 children based on clinical and imaging features with incidence of 7.4% (4 had recurrent episodes). Common manifestations included fever (98%), pain abdomen (88%), and diarrhea (83%). Hypoalbuminemia was observed in 78% of patients. Large bowel involvement (94%) with diffuse bowel involvement (63%) and pancolitis (64%) were common. Fecal calprotectin was significantly elevated in NEC group than non-NEC group and healthy controls (median: 87, 53, and 42 µg/g, respectively). A higher degree of gut dysbiosis was observed in children with NEC with higher isolation of Bacteroides and infrequent isolation of Lactobacilli. Mortality rate of 23% was observed. Only the presence of free fluid predicted higher mortality. Though levels of fecal calprotectin and gut dysbiosis were higher in NEC, they did not increase mortality. Isolation of Bacteroides and absence of Lactobacilli predicted a longer duration of intravenous alimentation.

CONCLUSIONS

NEC caused significant morbidity and mortality in pediatric cancer patients. Gut dysbiosis was significantly higher in NEC group suggesting a role in pathogenesis and influencing outcome. This highlights the role of targeted interventions towards gut dysbiosis like prebiotics and probiotics.

Investigation of typhlitis in bone marrow transplant patients in a stem cell transplant unit

Typhlitis is a special type of enterocolitis that specifically develops in immunosuppressive patients with hematological malignancies. Typhlitis is a common consideration after bone marrow transplantation due to high-dose chemotherapy that is used in conditioning regimens those contain high-dose cytotoxic chemotherapeutic agents. Although there are several studies about typhlitis during chemotherapy or in leukemia patients, there is not enough data evaluating its relationship between stem cell transplant in adults. Therefore, the current study aimed to analyze the possible causes that may lead to the development of typhlitis in hematopoietic stem cell recipient patients. This retrospective study included 210 adult patients who underwent bone marrow transplantation between January 2017 and December 2019. Pediatric patients (patients younger than 18 years of age) were excluded. Patients' data were evaluated to determine their effects on typhlitis and the mortality risk of the patients with typhlitis. The analysis of the variables was performed using the IBM SPSS Statistics for Windows version 26 (IBM Corp., Armonk, NY).Variables were analyzed at a 95% confidence level and a P value <0.05 was considered significant. Typhlitis developed in 23 (10.9%) transplant patients. Male sex, length of hospital stay, presence of febrile neutropenia, antibiotic and antifungal use, need for switching antibiotics, duration of neutropenia, diarrhea and antibiotic use in days were risk factors for development of typhlitis. It was observed that 100-days mortality was higher in typhlitis group reaching to a statistical significance (P < .05). In multiple logistic regression analysis, presence of mucositis and additional source of infection were determined as independent risk factors for the development of typhlitis in bone marrow transplant patients. This study provides valuable information for bone marrow transplant patients through an analysis of risk factors for the development of typhlitis. According to our results, mucositis and additional bacterial infections were found as risk factors for typhlitis therefore it would be beneficial for clinicians to consider these factors in patient follow-up. However, due to the retrospective nature of our study, prospective studies are needed to investigate risk factors and optimum treatment methods for typhlitis.

Neutropenic Enterocolitis as a Complication of Autologous Stem Cell Transplant in Patients With Multiple Myeloma: A Case Series

Neutropenic enterocolitis (NE) is a rare but severe complication occurring in neutropenic patients undergoing intensive chemotherapy. Mortality is high, so early diagnosis is required to start urgent medical or surgical treatment. Data analysis of the development of NE after hematopoietic stem cell transplantation remains scarce. The aim of this case series is to discuss five out of 100 patients receiving autologous stem cell transplants (ASCTs) for multiple myeloma complicated with NE between 2016 and 2020 in the hematology department of the Cheikh Khalifa International University Hospital, Casablanca, Morocco. The patients were diagnosed with IgA and IgG multiple myeloma and aged between 58 to 64 years. They received induction therapy with four cycles of a triplet regimen including a proteasome inhibitor, an immunomodulatory drug, and corticosteroids, allowing a complete remission. Intensification was based on ASCT with melphalan at 200 mg/m2. The period of aplasia was marked by the sudden appearance of NE, diagnosed based on clinical, biological, and imaging criteria. Treatment included antibiotherapy and supportive care. We report no complications in our cases, nor the need for surgical care. Therefore, we consider that early diagnosis and treatment allowed a good evolution in our case series. The management of NE must be multidisciplinary associating hematologists, gastroenterologists, radiologists, and biologists. More studies and trials are needed to establish specific diagnostic criteria and better treatment options. 

Gastrointestinal Surgical Emergencies in the Neutropenic Immunocompromised Patient

Surgeons encounter neutropenic patients through elective or emergency consultation with increasing regularity. As medical management continues to extend the lives of patients with benign hematologic diseases, hematologic malignancies, solid malignancies, or iatrogenic neutropenia, more patients are presenting with infectious complications caused and/or complicated by their neutropenia. This leaves surgeons in the difficult position of managing medically fragile patients with unusual presentations of common disease processes. These patients often fall outside of classical guidelines and treatment pathways. Many studies addressing these issues are retrospective and non-randomized. Here, we review common emergency gastrointestinal surgery scenarios and their management in the setting of a neutropenic patient. While biliary disease, appendicitis, anorectal disease, and perforations will be covered in detail, an extensive appreciation of a patient's medical or oncologic disease course and appropriate utilization of consultants such as interventional radiology, gastroenterology, and hematology is often necessary.

Neutropenic Enterocolitis and Sepsis: Towards the Definition of a Pathologic Profile

Background: Neutropenic enterocolitis (NE), which in the past was also known as typhlitis or ileocecal syndrome for the segment of the gastrointestinal tract most affected, is a nosological entity that is difficult to diagnose and whose pathogenesis is not fully known to date. Initially described in pediatric patients with leukemic diseases, it has been gradually reported in adults with hematological malignancies and non-hematological conditions, such as leukemia, lymphoma, multiple myeloma, aplastic anemia, and also myelodysplastic syndromes, as well as being associated with other immunosuppressive causes such as AIDS treatment, therapy for solid tumors, and organ transplantation. Therefore, it is associated with high mortality due to the rapid evolution in worse clinical pictures: rapid progression to ischemia, necrosis, hemorrhage, perforation, multisystem organ failure, and sepsis. Case report: A case report is included to exemplify the clinical profile of patients with NE who develop sepsis. Literature Review: To identify a specific profile of subjects affected by neutropenic enterocolitis and the entity of the clinical condition most frequently associated with septic evolution, a systematic review of the literature was conducted. The inclusion criteria were as follows: English language, full-text availability, human subjects, and adult subjects. Finally, the papers were selected after the evaluation of the title and abstract to evaluate their congruity with the subject of this manuscript. Following these procedures, 19 eligible empirical studies were included in the present review. Conclusions: Despite the recent interest and the growing number of publications targeting sepsis and intending to identify biomarkers useful for its diagnosis, prognosis, and for the understanding of its pathogenesis, and especially for multi-organ dysfunction, and despite the extensive research period of the literature review, the number of publications on the topic “neutropenic enterocolitis and sepsis” appears to be very small. In any case, the extrapolated data allowed us to conclude that the integration of medical history, clinical and laboratory data, radiological imaging, and macroscopic and histological investigations can allow us to identify a specific pathological profile.

Neutropenic Enterocolitis Complicating Induction Chemotherapy in an Acute Myeloid Leukemia Patient

Neutropenic enterocolitis is a rare inflammatory condition of the ileocecum. Clinicians should be aware of neutropenic enterocolitis in neutropenic patients with hematologic malignancies undergoing chemotherapy as it portends a poor prognosis if not diagnosed early in its course. We report a patient diagnosed with neutropenic enterocolitis within one week of receiving induction chemotherapy for acute myeloid leukemia. 

Neutropenic enterocolitis: A clinico-pathological review

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.

Clinical Presentation, Prognostic Factors, and Outcome in Neutropenic Enteropathy of Childhood Leukemia

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.

Neutropenic enterocolitis (typhlitis) in a pediatric renal transplant patient. A case report and review of the literature

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.

Typhlitis (neutropenic enterocolitis) in patients with acute leukemia: a review

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.

Cyclophosphamide-associated enteritis: A rare association with severe enteritis

Cyclophosphamide is a potent cytotoxic agent used in many clinical settings. The main risks of cyclophosphamide therapy include hematological disorders, infertility, hemorrhagic cystitis and malignancies. Gastrointestinal side effects reported to date are often non-specific and not severe. We present the first case of a fatal small bowel enteritis and pan-colitis which appears to be associated with cyclophosphamide. We aim to raise the readers’ awareness of this significant adverse event to facilitate clinical suspicion and early recognition in potential future cases.

Gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy in the years 2000

AIM: To review gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy. To look at gut microflora features in oncology children.

METHODS: We selected studies published after year 2000, excluding trials on transplanted pediatric patients. We searched English language publications in MEDLINE using the keywords: “gastrointestinal infection AND antineoplastic chemotherapy AND children”, “gastrointestinal infection AND oncology AND children”, “liver infection AND antineoplastic chemotherapy AND children”, “liver abscess AND chemotherapy AND child”, “neutropenic enterocolitis AND chemotherapy AND children”, “thyphlitis AND chemotherapy AND children”, “infectious diarrhea AND children AND oncology”, “abdominal pain AND infection AND children AND oncology”, “perianal sepsis AND children AND oncology”, “colonic pseudo-obstruction AND oncology AND child AND chemotherapy”, “microflora AND children AND malignancy”, “microbiota AND children AND malignancy”, “fungal flora AND children AND malignancy”. We also analysed evidence from several articles and book references.

RESULTS: Gastrointestinal and liver infections represent a major cause of morbidity and mortality in children undergoing antineoplastic chemotherapy. Antineoplastic drugs cause immunosuppression in addition to direct toxicity, predisposing to infections, although the specific risk is variable according to disease and host features. Common pathogens potentially induce severe diseases whereas opportunistic microorganisms may attack vulnerable hosts. Clinical manifestations can be subtle and not specific. In addition, several conditions are rare and diagnostic process and treatments are not standardized. Diagnosis may be challenging, however early diagnosis is needed for quick and appropriate interventions. Interestingly, the source of infection in those children can be exogenous or endogenous. Indeed, mucosal damage may allow the penetrance of endogenous microbes towards the bowel wall and their translocation into the bloodstream. However, only limited knowledge of intestinal dysbiosis in oncology children is available.

CONCLUSION: The diagnostic work-up requires a multimodal approach and should be implemented (also by further studies on new biomarkers) for a prompt and individualized therapy.

Antibiotic use before chemotherapy: a risk factor for developing neutropenic colitis in children with leukemia

BACKGROUND

It has been shown that the use of antimicrobials is a determinant that favors intestinal dysbiosis. The objective of this study is to establish the association between the previous use of antimicrobials and the development of neutropenic colitis (NC).

METHODS

A case-control study was carried out with subjects diagnosed with acute lymphoblastic leukemia from 2004 to July 2013. They were identified by cross-referencing the databases from the computing area and the records from the pediatric hematology section. Cases were children with neutropenia and fever, abdominal distension and pain, diarrhea or constipation, and ultrasonography or computed tomography showing an intestinal wall thickness of ≥4 mm. Controls were children with acute lymphoblastic leukemia with neutropenia and fever, with or without gastrointestinal symptomatology, but without images of NC.

RESULTS

Thirty-eight cases and 75 controls were included. The factors associated with the development of NC were severe neutropenia (odds ratio [OR], 12.4; 95% confidence interval [CI], 3-51; P=0.00001), the use of antimicrobials for >10 days, within the month previous to the appearance of NC (OR, 12.4; 95% CI, 3-51; P=0.00001), and use of doxorubicin (OR, 5.43, 95% CI, 2.1-13.8, P=0.00004). In particular, the risk of developing CN was 3.46 (95% CI, 0.88-14; P=0.04) when ceftriaxone was used.

CONCLUSIONS

The use of antimicrobials during >10 days before the administration of chemotherapy is a risk factor for developing NC, along with other factors previously studied.

Embolisation for caecal bleeding in a child with typhlitis

A 16-year-old girl being treated for a relapse of promyelocytic leukaemia developed typhlitis of the caecum and ascending colon related to Klebsiella septicaemia during the neutropenic phase, 2 weeks after the start of induction treatment with chemotherapy. After 10 days of treatment with parenteral feeding and antibiotics, massive rectal blood loss occurred, causing haemodynamic instability. Contrast-enhanced abdominal CT showed contrast extravasation in the caecal lumen. This life-threatening situation prompted visceral angiography, which confirmed a contrast blush in the caecum. Subsequent embolisation resulted in haemodynamic stability.

Concomitant typhlitis and Clostridium difficile colitis developed after first R-CHOP chemotherapy in a non-Hodgkin lymphoma patient

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.

Recurrent neutropenic enterocolitis in a pediatric patient

Management of an 8-year-old boy with Hodgkin lymphoma is presented. The patient had several recurrences of neutropenic enterocolitis and eventually required ileocecectomy. A review of the literature on this difficult problem affecting pediatric oncology patients is presented.

Surgical management of complications of multimodal therapy

Multimodality therapies that include surgery, chemotherapy, radiotherapy, and various newer forms of targeted therapies have been commonly applied in childhood cancers. Such modalities are associated with complications that may adversely affect the outcome of cancer treatment. Acute complications that require surgical management form the focus of our discussion. These patients are often compromised by immunosuppression, thrombocytopenia, and malnutrition. The complications discussed include typhlitis, invasive aspergillosis (IA), pancreatitis, hemorrhagic cystitis, gastrointestinal hemorrhage, necrotizing skin and soft-tissue infections, and perianal infection. Familiarity with the spectrum of complications and their appropriate management approaches will minimize the patients' morbidity.

Management of neutropenic enterocolitis in children with cancer

AIM

To describe the symptoms, clinical management and short-term outcome in a series of paediatric oncology patients with severe typhlitis following conservative treatment.

METHODS

Twelve episodes of severe typhlitis in 11 children with cancer treated at the paediatric oncology ward at Queen Silvias Children's Hospital between 1995 and 2006 were analysed retrospectively. Data on symptoms, radiological findings, laboratory status and treatment as well as outcome were collected and analysed.

RESULTS

In all episodes, the classical signs of neutropenia, fever, abdominal pain and thickening of the bowel wall were present. All were successfully treated with bowel rest, broadspectrum antibiotics and supportive care. After recovery from typhlitis, three patients needed surgical intervention because of complications.

CONCLUSION

A high clinical suspicion combined with radiological imaging aids early diagnosis. Predisposing factors for developing typhlitis were haematologic malignancy and treatment with chemotherapy within 3 weeks of onset. Supportive care, bowel rest including parenteral nutrition, correction of cytopenias and aggressive antimicrobial treatment is essential. Measurements of C-reactive protein in blood may be of benefit when assessing the clinical course.

Typhlitis in acute childhood leukemia

OBJECTIVE

To review our experience with typhlitis among children treated for acute leukemia.

MATERIAL AND METHODS

The medical records of children with acute leukemia and typhlitis between 2006 and 2009 were reviewed for demographics and symptoms, and for microbiological and imaging findings.

RESULTS

In the 75 children with acute leukemia--54 with acute lymphoblastic leukemia (ALL) and 21 with acute myeloid leukemia (AML)--there were 10 episodes of typhlitis (4.5%) that developed during 221 periods of severe neutropenia. The cumulative risk of typhlitis was 7.4% in patients with ALL and 28.5% in patients with AML. Frequent symptoms were: abdominal pain and tenderness (100% each); fever and nausea (90% each); emesis (80%); diarrhea (50%), and hypotension, peritonitis and abdominal distension (10% each). The median duration of symptoms was 6 days (range: 2-11 days), and that of neutropenia 14 days (range: 3-25 days). All patients were treated medically and none surgically. Two patients died because of typhlitis and sepsis.

CONCLUSIONS

In our study, the rate of typhlitis among leukemic children was 4.5%; however, the mortality rate was 20%. Thus, rapid identification and timely, aggressive medical intervention are necessary to reduce the morbidity and mortality from typhlitis.

Neutropenic colitis in children

BACKGROUND

Neutropenic colitis (NC) or typhlitis has an incidence of approximately 5% in patients receiving chemotherapy for malignancy. The precise cause is unknown, but almost all patients are neutropenic; most profoundly so. We reviewed our experience with neutropenic colitis over the past 10 y to assess the incidence, management, and outcome.

MATERIALS AND METHODS

Hospital records were reviewed after obtaining IRB approval (# 10-10-184E). There were 1224 children treated for cancer at our institution over the study interval. Neutropenic colitis was strictly defined as the presence of both clinical and radiographic findings consistent with the diagnosis, since there are no definitive diagnostic criteria. Patients with confirmed appendicitis were excluded. Medical management consisted of bowel rest and/or decompression, broad-spectrum IV antibiotics and anti-fungal coverage, and serial clinical exams and radiographic studies. Clinical deterioration and free air were the primary indications for surgery. Demographic factors, signs, symptoms, clinical presentation, underlying disease process, white blood cell count (WBC), and absolute neutrophil count (ANC) prior to the onset of the disease, treatment, and outcome were analyzed.

RESULTS

Neutropenic colitis was confirmed in 17 children (1.4% incidence). Three patients had more than one episode. Leukemia was the most common underlying diagnosis (53%). There was no gender predominance, and the mean age at diagnosis was 8.4 y. Mean WBC and ANC at onset were 670 and 164, respectively. A sharp decline in the ANC usually immediately preceded the onset of NC; 2/17 (12%) underwent operation, but both patients had only pneumatosis at exploration. Overall survival was 9/17 (53%), but no deaths were directly attributable to the colitis.

CONCLUSION

Neutropenic colitis is an uncommon occurrence in children with neoplasia (1.4% in the current study). Leukemia is the most common cause. A precipitous decline in ANC usually occurs prior to the onset of NC. Most patients do not require operation and the overall mortality directly attributable to NC is low.