Neutropenic enterocolitis, a growing concern in the era of widespread use of aggressive chemotherapy.

Neutropenic enterocolitis (NEC) is a life-threatening disease with substantial morbidity and mortality, seen primarily in patients with hematologic malignancies. The frequency of NEC has increased with the widespread use of chemotherapeutic agents such as the taxanes, which cause severe gastrointestinal mucositis. Neutropenic patients with fever and abdominal symptoms (cramping, pain, distention, diarrhea, GI bleeding), should undergo evaluation of the abdomen for bowel wall thickening of >4 mm, the hallmark of NEC. Clostridium difficile infection should be ruled out, as well as other etiologies such as graft-versus-host disease. Complications include bacteremia, which is often polymicrobial, hemorrhage, and bowel wall perforation/abscess formation. Management includes bowel rest, correction of cytopathies and coagulopathies, and broad spectrum antibiotics and antifungal agents. Surgical intervention may be necessary to manage complications such as hemorrhage and perforation and should be delayed, if possible, until recovery from neutropenia.

Variant neutropenic enterocolitis presenting as acute appendicitis.

BACKGROUND: Neutropenic enterocolitis (NE) is characterized by fever, abdominal pain, and neutropenia. Observed most commonly in relation to solid, hematologic, and lymphoproliferative malignant tumors and their treatment, this disease entity may involve a wide area of the gastrointestinal tract. We report the first case of NE with isolated appendiceal involvement in a non-oncologic neutropenic patient who was managed successfully medically. In addition, we formally recognize neutropenic appendicitis as a variant of NE and differentiate it from acute non-neutropenic appendicitis. METHODS: Case report and review of the pertinent English language literature. CASE REPORT: A 50-year-old man with seronegative large-joint arthritis presented emergently with a one-day history of subjective fever and acute-onset abdominal pain in the setting of recently developed sulfasalazine-induced agranulocytosis. Abdominal examination revealed mild-to-moderate tenderness and rebound tenderness in the right lower quadrant. Computed tomography (CT) of the abdomen demonstrated findings consistent with acute appendicitis. The patient improved clinically with non-operative management including a broad-spectrum antibiotic, with normalization of the white blood cell count four days after initiation of granulocyte-colony stimulating factor therapy. CONCLUSIONS: Given the similarity in clinical presentation and CT imaging in patients with neutropenic and non-neutropenic appendicitis, accurate recognition of neutropenic appendicitis rests on a thorough patient history and a high index of suspicion in febrile neutropenic patients.