Neutropenic enterocolitis (NE), commonly referred to as typhlitis (from the Greek typhlos meaning blind / closed) or ileocecal syndrome, is an increasingly common complication of neutropenic pediatric patients, with a reported incidence of 0.8% – 26%. This is especially evident as the use of aggressive chemotherapy regimens in pediatric patients increases. While typically affecting the cecum, other large and small bowel involvement has been described. Symptoms often present within 2 weeks of therapy completion, concurrently with the expected leukocytosis. We present a case of NE with typical and atypical imaging findings. The patient was a previously healthy 7-year-old male that presented with a two-week history of daily fevers, increased fatigue, abdominal pain, and easy bruising. Flow cytometry confirmed the diagnosis of suspected B-cell Acute Lymphoblastic Leukemia/Lymphoma (ALL) and the patient was started on induction chemotherapy for High Risk ALL. On the patients last day of induction (day 7), the patient began developing worsening lower abdominal pain and bloody stool. Supine radiograph demonstrated a non-specific paucity of gas in abdomen. The patient continued to decline clinically and the physical exam also showed worsening distention with involuntary guarding. A contrast enhanced computed tomography (CT) was ordered which demonstrated NE with significant wall thickening in both the cecum and rectum. Despite ECMO and other heroic efforts the patient expired. There is one reported case in the available English literature of neutropenic enterocolitis involving the rectum. Our case demonstrates the typical location within the cecum and ascending colon, along with the rarely identified rectal involvement. It is hypothesized that an initial intestinal injury in an already immunocompromised state, allows for an increased inflammatory response and vulnerability to opportunistic bacterial invasion. Based on reports outlining colonic wall thickening in patients with NE seen on ultrasound, there is a reported mortality rate of 60% at 10 mm or greater and only 4.2% at <10 mm. The significant wall thickening present in this case was an ominous sign. However, the lack of adequate research regarding the management NE makes it difficult to create a standardized treatment protocol. This case demonstrates a common and uncommon location of NE within the colon and further demonstrates the importance of early supportive intervention when NE is suspected.
SPR 2020 Annual Meeting & Postgraduate Course