Typhlitis, also known as necrotizing enterocolitis, is a devastating infection that can affect those with hematologic malignancies after receiving chemotherapy.  It usually occurs when the patient is neutropenic and the mortality is high.  This condition was previously thought to affect only children, but adults have been diagnosed as well. 

The most common types of cancer in which typhlitis is seen include leukemia, multiple myeloma, and myeloproliferative disorders.  This is usually not seen in solid organ tumors, although case reports do exist.  Typhlitis is usually seen at the neutropenic nadir, usually 7 to 14 days after the most recent chemotherapy.  These patients will present with abdominal pain, usually right lower quadrant in nature, and fever.  Differentiating typhlitis from other infections such as appendicitis is nearly impossible without imaging.  Many different studies have looked at CT vs US in diagnosing typhlitis, and most providers choose CT as it will also help rule out other etiologies.  Both CT and US should show a thickened cecum and free fluid in the abdomen. The cecum is affected so often because it has reduced blood flow and large distension.

The management depends on the findings on exam and imaging.  Patients with shock, peritonitis, uncontrolled hemorrhage, or free air in the abdomen should go directly to laparotomy with antibiotics on the way.  If the patient is stable and has not immediate indications for surgery, medical management is indicated with broad spectrum antibiotics, fluid resuscitation, and supportive measures.  Anaerobic coverage should also be included with the broad spectrum antibiotics.  Also, it is recommended that clostridium difficile should also be covered until it is ruled out.  If the fever continues for over 72 hours with the above treatment, the diagnosis should be reconsidered; if the presentation is still consistent with typhlitis, anti-fungal coverage should be added, either with amphotericin B or fluconazole.

NG tube may be necessary for bowel rest.  Another treatment option is granulocyte colony-stimulating factor (G-CSF), which potentially could improve leukocyte formation and help fight the infection.  The mortality rate is 40-50%, even with treatment, although newer studies are starting to quote smaller numbers with more aggressive treatment.  Further studies need to be conducted to determine current mortality rates.  Neutropenic patients after chemotherapy can present with a multitude of different infections, but typhlitis should be high on your differential if your patient has abdominal pain of uncertain etiology.

McCarville M.  Evaluation of typlitis in children: CT versus US.  Pediatr Radiol. 2006; 36: 890–891.

Morgan C, Tillett T, et al.  Management of uncommon chemotherapy-induced
emergencies.  Lancet Oncology.  2011; 12: 806–14.

Wong Kee Song L, Mason N.  Typhlitis (Neutropenic enterocolitis).  Uptodate.com.  Updated June, 2011.

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