Neutropenic enterocolitis in a child with acute myeloid leukemia successfully treated with early surgical intervention

Chemotherapy-Induced Jejunal Perforations as an Atypical Presentation of Neutropenic Enterocolitis in an Acute Leukemia Patient

Neutropenic enterocolitis (NE) is a potentially life-threatening condition, primarily affecting neutropenic patients with hematologic malignancies. The clinical manifestations of NE in patients receiving antineoplastic drugs range from fever, diarrhea, nausea, vomiting, and abdominal pain to intestinal perforation and shock. We report the case of a 12-year-old boy with acute myelogenous leukemia, undergoing chemotherapy, who presented with an atypical case of NE. Due to numerous jejunal perforations and severe rectal bleeding, he experienced abdominal distension without any accompanying tenderness and the unexpected rapid onset of shock. Surgery was performed, and his postoperative course was uneventful. However, seven days later, Pseudomonas aeruginosa-induced sepsis made his condition rapidly worse due to severe neutropenia and thrombocytopenia. Despite intensive supportive therapy, the patient unfortunately passed away. NE remains a life-threatening complication in pediatric immunosuppressed leukemic patients. A high index of suspicion, prompt diagnosis, aggressive treatment with broad-spectrum antibiotics, and correction of fluid-electrolyte imbalances are crucial in reducing morbidity and mortality.

A surgeon's predicament: Clinical predictors of surgery and mortality in neutropenic enterocolitis

BACKGROUND

Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality.

METHODS

A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality.

RESULTS

Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps < 0.05).

CONCLUSION

Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions.