RESUMO
Typhlitis, is also known as neutropenic enterocolitis, affects the cecum and distal ileum. It was frequently encountered in pediatric patients who were undergoing treatment for leukemia. Nonetheless, it can affect adult patients, regardless of the cause of the immunosuppression. We report the case of a 20-year-old patient who was receiving chemotherapy for Osteosarcoma, who had a 6-day history of nausea and vomiting, fever sensation, diarrhea, and diffuse abdominal pain. Physical examination was relevant for hemodynamic instability, a distended and tender abdomen predominantly in the right iliac fossa. The laboratory workup showed severe neutropenia, thrombocytopenia, and electrolyte disturbances. The image studies evidenced edema of the ascending colon and cecum. Treatment was started with vasopressor support, correction of electrolyte alterations, blood cell and platelet transfusion, G-CSF, hydration, broad spectrum antibiotic therapy, initially with adequate clinical and laboratory response. After a few days, he presented lower gastrointestinal bleeding which was treated by conservative management. In conclusion, typhlitis must be suspected in every patient developing neutropenia as a reaction to chemotherapy and who also presents gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and intense abdominal pain.
Assuntos
Enterocolite Neutropênica , Neutropenia , Tiflite , Masculino , Adulto , Humanos , Criança , Adulto Jovem , Enterocolite Neutropênica/diagnóstico , Enterocolite Neutropênica/etiologia , Enterocolite Neutropênica/terapia , Tiflite/complicações , Neutropenia/complicações , Dor Abdominal/etiologia , Diarreia , VômitoRESUMO
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.
Assuntos
Enterocolite Neutropênica/patologia , Intestinos/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Criança , Pré-Escolar , Diagnóstico Diferencial , Erros de Diagnóstico , Enterocolite Neutropênica/etiologia , Enterocolite Neutropênica/mortalidade , Enterocolite Neutropênica/terapia , Feminino , Humanos , Intestinos/diagnóstico por imagem , Intestinos/cirurgia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Tomografia Computadorizada por Raios X , Estados Unidos , Adulto JovemRESUMO
Patients with hematologic malignancies are susceptible to serious complications due to immunosuppression. Neutropenic-related infection is one of the major causes of morbidity and mortality in this group of diseases. Febrile neutropenia is a common complication of the hematologic neoplasm itself or chemotherapy, and has worse prognosis if prolonged (lasting more than 7 days) or severe (neutrophil count below 500 cells per µL). Among the usual sites of infection, we highlight the neutropenic enterocolitis and perianal infection as gastrointestinal complications of greater interest to the colorectal surgeon. Although most cases respond to conservative treatment, a portion of patients will need surgery for complete recovery. (AU)
Os pacientes com neoplasias hematológicas estão sujeitos a uma séria de complicações devido à imunossupressão. Infecção é umas das principais causas de morbidade e mortalidade nesse grupo de doenças. A neutropenia febril é uma complicação frequente da própria doença onco-hematológica ou da quimioterapia, e apresenta pior prognóstico se prolongada (duração acima de 7 dias) ou severa (contagem de neutrófilos inferior a 500 células por microlitro). Dentre os focos de infecção mais comuns destacamos a enterocolite neutropênica e a infecção perianal como complicações de maior interesse para o cirurgião colorretal. Apesar de grande parte dos casos apresentar boa resposta ao tratamento conservador, uma parcela de pacientes necessitará de cirurgia para completa recuperação.
Assuntos
Humanos , Doenças Retais , Enterocolite Neutropênica/terapia , Neutropenia Febril , Enterocolite Neutropênica/diagnósticoRESUMO
La enterocolitis neutropénica es una enteropatía necrotizante en pacientes con neutropenia severa relacionada con tratamientos quimioterápicos. Se presenta el caso de un paciente HIV positivo que desarrolló una enterocolitis neutropénica en el contexto de un tratamiento quimioterápico por Linfoma de Hodgkin. Presentaba leucopenia 400 leucocitos/mm3 y cuadro clínico compatible. La ecografía mostró engrosamiento de las paredes del ciego, del colon ascendente, y del íleon terminal. No hubo aislamiento microbiológico. Recibió tratamiento empírico con cefepime, vancomicina, y metronidazol con buena respuesta clínica y ecográfica. En el paciente con SIDA, diversas entidades pueden presentarse con dolor abdominal y engrosamiento de las paredes intestinales, como por ejemplo Citomegalovirus, Clostridium difficile, tuberculosis, histoplasmosis y linfomas, entre otras. El avance tecnológico, y las características ponderales de estos pacientes (bajo peso) permiten utilizar transductores de alta frecuencia para evaluar el tracto gastrointestinal y detectar mínimas lesiones en otros órganos abdominales, aportando al diagnóstico diferencial.(AU)
Assuntos
Humanos , Masculino , Adulto , Enterocolite Neutropênica/complicações , Enterocolite Neutropênica/terapia , Enterocolite Neutropênica/diagnóstico por imagem , Síndrome da Imunodeficiência Adquirida/complicações , Tratamento Farmacológico/estatística & dados numéricosRESUMO
La enterocolitis neutropénica es una enteropatía necrotizante en pacientes con neutropenia severa relacionada con tratamientos quimioterápicos. Se presenta el caso de un paciente HIV positivo que desarrolló una enterocolitis neutropénica en el contexto de un tratamiento quimioterápico por Linfoma de Hodgkin. Presentaba leucopenia 400 leucocitos/mm3 y cuadro clínico compatible. La ecografía mostró engrosamiento de las paredes del ciego, del colon ascendente, y del íleon terminal. No hubo aislamiento microbiológico. Recibió tratamiento empírico con cefepime, vancomicina, y metronidazol con buena respuesta clínica y ecográfica. En el paciente con SIDA, diversas entidades pueden presentarse con dolor abdominal y engrosamiento de las paredes intestinales, como por ejemplo Citomegalovirus, Clostridium difficile, tuberculosis, histoplasmosis y linfomas, entre otras. El avance tecnológico, y las características ponderales de estos pacientes (bajo peso) permiten utilizar transductores de alta frecuencia para evaluar el tracto gastrointestinal y detectar mínimas lesiones en otros órganos abdominales, aportando al diagnóstico diferencial.
Assuntos
Humanos , Masculino , Adulto , Enterocolite Neutropênica/complicações , Enterocolite Neutropênica/terapia , Enterocolite Neutropênica , Tratamento Farmacológico , Síndrome da Imunodeficiência Adquirida/complicaçõesRESUMO
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.