(1607) In a Tiff: A Case of Chemotherapy-Induced Typhlitis in the Setting of Hodgkin Lymphoma

Introduction: Typhlitis (aka neutropenic enterocolitis) comes from the Greek word typhlon meaning Cecum. It is a life-threatening event that occurs in those who are myelosuppressed in the setting of chemotherapeutic agents. The exact pathophysiology is not fully understood, yet it holds a 30-50% mortality rate in those with an intestinal mucosal injury, immunosuppression, and neutropenia. Being neutropenic suppresses the ability to protect the mucosa and given that the cecum has more lymphoid tissue, neutropenic enterocolitis primarily affects this part of the colon. Also known to this diagnosis are the infections that can occur, such as Clostridium septicum, E. coli, and Klebsiella pneumoniae.

Description: 56 y/o male presented with right-sided abdominal pain, fever, and tachycardia. History included EBV+ Hodgkin Lymphoma (receiving ABVD - Doxorubicin, Bleomycin, Vincristine, and Procarbazine), paroxysmal atrial fibrillation and COPD. The patient was in atrial fibrillation with rapid ventricular response, pancytopenic, neutropenic (absolute neutrophil count < 5), and with lactic acidosis. He required cardioversion twice and was started on an amiodarone gtt. A CT Angiogram of the Chest/Abdomen/Pelvis revealed moderate to severe ascending and transverse colitis, with phlegmonous change to the cecum, prominent loops of fluid-filled bowel, a borderline dilated jejunum, and several foci of pneumatosis. He required admission to the ICU given severe sepsis. He quickly declined, requiring intubation and vasopressor support (maxed on four). He was started on empiric Vancomycin, Cefepime, and Metronidazole, found to have Klebsiella pneumoniae bacteremia and in florid septic shock. Unfortunately, he passed within 12 hours of arrival despite all efforts.

Discussion: Neutropenic Enterocolitis, an oncologic emergency, has an approximate incidence of 5.6%. Despite its rarity, the mortality rate stresses the importance of clinicians maintaining a high index of suspicion for it. Few studies have also shown that utilizing ultrasound may be an appropriate form of quickly diagnosing the condition. Fast recognition is crucial with the immediate initiation of empiric antibiotics. Life and death hang in the balance of timely recognition and intervention.