Typhlitis in a post-chemotherapy lymphoma patient; images in clinical medicine

Ultrasound diagnosis of typhlitis

PURPOSE

Typhlitis, also known as neutropenic colitis, is a rare inflammatory condition and a potentially life-threatening disease process that typically involves the cecum. Delay in diagnosis may lead to a fatal prognosis with a death rate of 21-48%. Ultrasound evaluation of right lower quadrant may lead to an accurate and rapid diagnosis.

METHODS

We describe the case of a 59-year-old female with advanced Churg-Strauss syndrome treated with cyclophosphamide, with acute right lower quadrant pain.

RESULTS

Ultrasound was the first diagnostic step in the diagnosis of typhlitis. Sonographic findings were comparable to CT imaging.

CONCLUSIONS

Bowel bedside ultrasound evaluation in emergency settings may lead to a prompt and definitive diagnosis. Although CT is considered the gold standard in the diagnosis and staging of neutropenic colitis, ultrasound was able to identify the pathology accurately. Ultrasound findings of typhlitis are highly characteristic, showing circumferential wall thickening with predominant submucosa.

Concomitant typhlitis and Clostridium difficile colitis developed after first R-CHOP chemotherapy in a non-Hodgkin lymphoma patient

Typhlitis or neutropenic enterocolitis (NEC) is a life-threatening condition that occurs in neutropenic patients. Early recognition is crucial owing to high death rate. We present a case of a 54-year-old man, diagnosed with non-Hodgkin lymphoma who received a first cycle of rituximab, cyclophosphamide, hydroxydaunorubicin (doxorubicin), oncovin (vincristine), prednisolone (R-CHOP) chemotherapy 10 days prior presenting. He developed fever, mucositis, watery diarrhoea and right lower quadrant pain with rebound tenderness. He also had neutropenia, with an absolute neutrophil count of zero. CT abdomen confirmed the diagnosis of typhlitis, demonstrating characteristic terminal ileum, caecal and right-sided colon involvement. Moreover, stool PCR was also positive for toxigenic Clostridium difficile. Therefore, the patient was diagnosed with concomitant typhlitis and C difficile-associated diarrhoea (CDAD). He was empirically treated with intravenous cefepime, intravenous metronidazole and oral vancomycin. His symptoms resolved in 10 days. This case illustrated a successful medical treatment of typhlitis in concomitance with CDAD.