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PubMed2004

Significance of appendiceal thickening in association with typhlitis in pediatric oncology patients.

BACKGROUND: The management of pediatric oncology patients with imaging evidence of appendiceal thickening is complex because they are generally poor surgical candidates and often have confounding clinical findings. OBJECTIVE: We sought to determine the significance of appendiceal thickening in pediatric oncology patients who also had typhlitis. Specifically, we evaluated the impact of this finding on the duration of typhlitis, its clinical management, and outcome. MATERIALS AND METHODS: From a previous review of the management of typhlitis in 90 children with cancer at our institution, we identified 4 with imaging evidence of appendiceal thickening. We compared colonic wall measurements, duration of typhlitis symptoms, management, and outcome of patients with appendiceal thickening and typhlitis to patients with typhlitis alone. RESULTS: There was no significant difference in duration of typhlitis symptoms between patients with typhlitis only (15.6+/-1.2 days) and those with typhlitis and appendiceal thickening (14.5+/-5.8 days; P=0.9). Two patients with appendiceal thickening required surgical treatment for ischemic bowel, and two were treated medically. Only one patient in the typhlitis without appendiceal thickening group required surgical intervention. There were no deaths in children with appendiceal thickening; two patients died of complications of typhlitis alone. CONCLUSION: Our findings suggest that appendiceal thickening does not predict a prolonged course of typhlitis in pediatric oncology patients, but it may indicate an increased risk of serious complications from this disease process.

Adolescent↗
PubMed2002

Neutropenic enterocolitis (typhlitis) after pediatric bone marrow transplant.

BACKGROUND/PURPOSE: Neutropenic enterocolitis (typhlitis) is a common consideration after bone marrow transplantation. This study reviews the authors' experience with abdominal pain and typhlitis in an active pediatric bone marrow transplant program. METHODS: The Pediatric Bone Marrow Transplant Program Database was reviewed for patients presenting with abdominal pain or typhlitis. RESULTS: From 1993 to 2000 a total of 142 transplants have been performed. Of these, 97 patients had abdominal pain, and 5 had radiologically proven typhlitis. Nonspecific abdominal pain developed on the 12 +/- 11th day posttransplant, whereas patients in whom typhlitis developed were diagnosed on day 15.5 +/- 7. All patients were treated with prophylactic antibiotics consisting of acyclovir, fluconazole, and septra. With the onset of abdominal pain, 73 of 97 patients were placed on therapeutic antibiotics; patients identified with typhlitis had amphotericin plus GCSF added. No clinical features differentiated abdominal pain patients from typhlitis. Oral feeding and time of discharge was similar in both groups. Surgical intervention was not required, and no patients died with typhlitis. CONCLUSIONS: Abdominal pain is a common symptom after bone marrow transplant; however, typhlitis is relatively rare, and surgical intervention was not required in this series. Broad-spectrum (including fungal) antibiotic therapy appears to be an effective treatment for typhlitis in this patient population.

Abdominal Pain↗
PubMed1986

The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia.

The treatment of acute leukemia in childhood has been increasingly successful. Infectious complications are the major cause of morbidity and mortality among these patients receiving aggressive chemotherapy. In particular, neutropenic enterocolitis or typhlitis has had a reported mortality of 50% to 100%. The authors reviewed a series of 77 previously untreated patients with acute myelogenous leukemia begun on treatment from March 1976 to June 1984 to better define the characteristics of typhlitis and its optimum management. Twenty-five patients had episodes of typhlitis, characterized by fever, abdominal pain, and tenderness, occurring during periods of neutropenia. Ten of these patients had watery diarrhea as a major additional symptom, and nine patients had a significant episode of gastrointestinal bleeding. In seven instances, blood culture results were positive, all for intestinal flora. The episodes of typhlitis occurred most frequently during the induction therapy (19 patients). Five patients experienced typhlitis during maintenance therapy, and one patient had acute appendicitis. Two patients had typhlitis during their reinduction therapy, and of note, one had had abdominal symptoms during her initial induction. All patients were treated initially with broad-spectrum antibiotics and bowel rest. Four criteria have been used for surgical intervention: (1) persistent gastrointestinal bleeding after resolution of neutropenia and thrombocytopenia and correction of clotting abnormalities; (2) evidence of free intraperitoneal perforation; (3) clinical deterioration requiring support with vasopressors, or large volumes of fluid, suggesting uncontrolled sepsis; and (4) development of symptoms of an intra-abdominal process, in the absence of neutropenia, which would normally require surgery. Using these criteria, five patients required surgical intervention for typhlitis or its sequelae and one for acute appendicitis. There was one perioperative death resulting from miliary tuberculosis. Among the 21 patients managed medically, there was 1 death resulting from typhlitis in a patient in whom surgery was deferred because of her multiple failures to enter remission.

Adolescent↗
PubMed1985

Typhlitis in adults.

Although described initially in children, typhlitis is an important clinical condition that may also occur in adults with hematologic malignancy or, less commonly, aplastic anemia. We describe 6 adult patients with typhlitis and review the salient features of this condition. In typhlitis, a necrotizing process of multifactorial origin involves the right colon alone or the right colon and other areas of the intestine as well. Secondary colonization of mucosal ulcers by colonic flora commonly leads to septicemia and pyrexia. Typhlitis may be associated with a variety of clinical and radiographic findings. However, a high index of suspicion and certain constellations of clinical and radiographic findings may lead to an accurate presumptive diagnosis of typhlitis, followed by the institution of appropriate therapy. Notwithstanding, the short-term prognosis for typhlitis remains poor.

Adolescent↗
PubMed1994

Typhlitis in a patient with acute lymphoblastic leukemia prior to the administration of chemotherapy.

PATIENTS AND METHODS: A 3-year-old girl with acute lymphoblastic leukemia developed typhlitis immediately after diagnosis and before the institution of chemotherapy. PURPOSE: Typhlitis is a necrotizing colitis that develops in immunodeficient patients with severe neutropenia. Most patients are leukemic children who are receiving or have received chemotherapy. Typhlitis in the absence of chemotherapy is rare. We report a fatal case of typhlitis in an untreated leukemic patient. RESULTS: This case emphasizes the multifactorial pathogenesis of typhlitis, which may occur in the absence of chemotherapy. CONCLUSIONS: Typhlitis should always be considered as a potential cause of acute sepsis and abdominal pain in a leukemic patient.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2000

Typhlitis complicating autologous blood stem cell transplantation for breast cancer.

Three cases of typhlitis occurring during autologous blood stem cell transplantation (ABSCT) for metastatic breast cancer are described. Typhlitis is a rare complication of neutropenia and has uncommonly been reported in the autologous transplant setting. Although it has been most commonly described in children with leukemia, typhlitis has increasingly been reported in adult leukemias and in association with neutropenia secondary to chemotherapy for a number of solid tumors. Only five previous cases of typhlitis in the setting of ABSCT have been described. Whereas diarrhea and fever are common toxicities associated with high-dose chemotherapy, it is likely that many cases of typhlitis go unrecognized. Bone Marrow Transplantation (2000) 25, 321-326.

Adult↗
PubMed2002

Successful nonoperative management of typhlitis in pediatric oncology patients.

BACKGROUND/PURPOSE: The optimal management for typhlitis in pediatric oncology patients has not always been clear from the medical literature. Trends have varied between operative and nonoperative approaches. The aim of this study was to review the successful nonoperative management of these patients at our institution over the last decade to further clarify management guidelines for this difficult problem. METHODS: Medical records of pediatric hematology and oncology patients up to 21 years of age with typhlitis diagnosed at the DeVos Children's Hospital from 1990 to 2000 were reviewed. RESULTS: Twelve patients were included. Ten patients (83%) with computed tomography (CT) scans suggestive of the diagnosis were treated successfully nonoperatively. Management usually included bowel rest, antibiotics, and supplemental parenteral nutrition. Two patients (17%) in whom CT scans were not obtained underwent surgery for presumed appendicitis and pneumoperitoneum, respectively. Typhlitis was found incidentally. In the latter patient, the pneumoperitoneum resulted from a perforated jejunum caused by graft-versus-host disease. This patient died of septic complications and was the only mortality in the series (8%). CONCLUSIONS: Pediatric cancer patients with typhlitis can be treated carefully nonoperatively with bowel rest, antibiotics, and supplemental nutrition. Usual indications for surgery (ie, perforation, clinical deterioration) still should be used. The early use of CT scanning helps to facilitate the diagnosis and may provide the ability to differentiate typhlitis from other abdominal diseases for which surgery would be indicated.

Adolescent↗
PubMed1993

Typhlitis in children with cancer: a 30-year experience.

We identified 24 children treated for malignancies between 1962 and 1992 who had antemortem diagnoses of typhlitis that were confirmed on review. The study criteria specified the presence of fever, abdominal pain, and tenderness, with radiological evidence of right-sided colonic inflammation. Typhlitis was most frequent in patients treated for acute leukemias. Computed tomography and ultrasonography were more sensitive than plain radiography (false-negative rates, 15%, 23%, and 48%, respectively). The wider availability of these sensitive procedures and the increased intensity of chemotherapeutic regimens may account for a marked increase in the incidence of typhlitis over the past 5 years. Most patients responded to aggressive medical management, and typhlitis was fatal in only two cases (1 of 21 cases managed medically and 1 of 3 taken to surgery). Seven patients are alive > 1 year following the diagnosis. These findings contrast with prior descriptions of typhlitis as a preterminal event. Computed tomography and/or ultrasonography should be performed in all neutropenic patients with right-lower-quadrant signs to permit prompt diagnosis and treatment.

Adolescent↗
PubMed1993

Typhlitis resulting from treatment with taxol and doxorubicin in patients with metastatic breast cancer.

BACKGROUND: Typhlitis is being recognized with increasing frequency as a serious complication of aggressive chemotherapy for hematologic and solid malignancies. METHODS: In this report the authors describe two cases of typhlitis in patients with metastatic breast cancer treated with taxol and doxorubicin. RESULTS: Both cases occurred during the first cycle of treatment with taxol (180 mg/m2) and doxorubicin (75 mg/m2), being given simultaneously as 72-hour continuous intravenous infusions. CONCLUSION: Two cases of typhlitis have occurred after combined treatment with taxol and doxorubicin, while typhlitis has not been described after treatment with either drug alone.

Adult↗
PubMed1988

The ultrasonographic diagnosis of typhlitis (neutropenic colitis).

Typhlitis is a necrotizing inflammatory disease of the cecum, usually with secondary infection. It is most often found in acute leukemia patients on chemotherapy but has also been reported in other patients on chemotherapeutic drugs. Diagnostic features of typhlitis have been reported on plain radiographs, barium enema, angiography, CT, and one other reported case with ultrasound. We report three cases of typhlitis with a characteristic echogenic thickening of the mucosa on ultrasound. The sonographic findings in the one previous report were identical to those of our three cases. We believe that the sonographic findings of typhlitis are unique and that ultrasound offers an easy noninvasive method of diagnosing this potentially lethal disease.

Adolescent↗
PubMed1989

Recurrent typhlitis. A disease resulting from aggressive chemotherapy.

Neutropenic typhlitis is a frequently fatal disease most commonly reported in leukemics. The authors have treated eight such patients over the last 18 months. All patients had abdominal pain and sepsis during chemotherapy-induced neutropenia. CT scanning was diagnostic in six patients thought to have typhlitis. Two patients were not diagnosed before exploratory laparotomy. The authors have found nonoperative treatment highly effective in patients who do not manifest signs of peritonitis, perforation, gastrointestinal hemorrhage, or clinical deterioration. Recurrent typhlitis was frequent after conservative therapy (recurrence rate, 67 percent), however. One patient underwent an elective right hemicolectomy after a second episode, and typhlitis did not recur despite neutropenia associated with a subsequent course of chemotherapy. It is concluded that successful treatment of this disease hinges on: 1) early diagnosis provided by a high index of suspicion and the use of CT scanning, 2) nonoperative treatment for uncomplicated cases, and 3) elective right hemicolectomy to prevent recurrence.

Adolescent↗
PubMed1986

Typhlitis: selective surgical management.

Typhlitis is a neutropenic enterocolitis of varying severity. Its incidence is increasing, particularly in patients with acute myelogenous leukemia undergoing high dose cytosine arabinoside chemotherapy. The onset is heralded by prodromal fever, watery or bloody diarrhea, abdominal distension, and nausea during the phase of severe neutropenia. The symptoms may then localize to the right lower quadrant with an associated increase in systemic toxicity. The diagnosis can be confirmed in these and other less specific cases by serial reexamination and abdominal radiographs, ultrasonography, computerized tomograms, or radionucleotide scans. The mainstay of management is complete bowel rest with nasogastric suction and total parenteral nutrition. Broad-spectrum combination antibiotics are essential, as is the avoidance of laxatives or antidiarrheal agents. Granulocyte support may be helpful. Patients with a history of nonspecific gastrointestinal complaints or of true typhlitis, successfully managed nonoperatively, should have prophylactic bowel rest and total parenteral nutrition instituted at the beginning of further chemotherapy. Patients with ongoing severe systemic sepsis who do not respond to chemotherapy and those with overt perforation, obstruction, massive hemorrhage, or abscess formation require surgical intervention. All necrotic material must be resected, usually by a right hemicolectomy, ileostomy, and mucous fistula. Divided ileostomy for less severe cases may be useful. Failure to remove the necrotic focus in these severely immunocompromised patients is fatal. With adequate recognition of typhlitis and its precipitating factors, the incidence of complications can be reduced through prevention and timely surgical intervention. Although typhlitis developed in a quarter of our acute myeloblastic leukemia patients, use of this combined approach was successful in all cases.

Adolescent↗
PubMed1999

Typhlitis.

OBJECTIVE: To provide an overview of the pathophysiological features and management of the clinical entity typhlitis. DATA SOURCES AND STUDY SELECTION: The data presented are derived from a review of the English-language literature on typhlitis. The majority of papers analysed were small clinical series. DATA EXTRACTION AND SYNTHESIS: Data derived from the literature review were collated. The major finding was that typhlitis comprises a number of different diseases characterized by the presence of right lower quadrant pain, an immunocompromised host and altered function of the mucosal barrier of the right colon. CONCLUSIONS: Typhlitis should be suspected in any immunocompromised patient presenting with right lower quadrant pain with compatible radiographic findings. Most patients can be treated conservatively with intravenously administered fluids and antibiotics, although surgery may be necessary if complications arise.

Enterocolitis↗
PubMed1992

[Systemic chronic candidiasis following typhlitis caused by Candida albicans].

Typhlitis is an infrequent infectious complication which may appear during a period of intense granulocytopenia, generally in patients with acute leukemia. The most common causal germs are Gram negative bacilli although the importance of Candida sp. as an etiologic agent of this disease is ever more frequent. The case of a 14 years old patient with acute lymphoblastic leukemia who, after chemotherapy treatment, presented typhlitis by Candida albicans followed by chronic systemic candidiasis (CSC) is described. The role that Candida albicans may play in some cases of typhlitis is discussed as is the relation between the appearance of typhlitis and the posterior development of CSC.

Adolescent↗
PubMed1990

Typhlitis. An 18-year experience and postmortem review.

A review of pediatric autopsy results at the Texas Children's Hospital, Baylor College of Medicine from 1970 through 1987 was conducted. Thirty-three cases of typhlitis were identified in patients with acute leukemia and two cases each in patients with lymphoblastic lymphoma and aplastic anemia. Patients ranged in age from 10 months to 17 years. Fifty-seven percent were male and 43% were female. All were myelosuppressed. A postmortem incidence rate of 24% was determined for patients with acute leukemia. Common symptoms included abdominal pain and distention in 78% of patients and acute lower gastrointestinal bleeding in 35%. Abdominal radiographs varied in spectrum from a nonspecific bowel gas pattern to frank right colonic pneumatosis intestinalis. Thirty-three patients received chemotherapy within 30 days before onset of abdominal symptoms. All patients were febrile (greater than 38.5 degrees C), and 33 received broad-spectrum antibiotics. Three patients received amphotericin B. Premortem, 84% of organisms cultured from blood were bacterial whereas 16% were fungal. Fungal pathogens accounted for 53% of new microorganisms seen at autopsy. Postmortem examination showed typhlitis in the following anatomic distributions: (1) confined to the cecum; (2) involving the cecum and ileum; (3) involving the cecum, ileum, and ascending colon; or (4) involving the cecum, with sporadic ulcers throughout the intestine. This review includes clinical and postmortem features of typhlitis and current strategies for diagnosis and management.

Adolescent↗
PubMedDate not supplied

Typhlitis as a rare cause of a psoas abscess.

Typhlitis is a life-threatening necrotizing process of the cecum associated with leukemia patients who have undergone chemotherapy. We present a rare complication of typhlitis in a boy with leukemia, in whom a right psoas abscess developed secondary to the inflammatory process of the cecum, with an emphasis on the computed tomographic findings of this severe and potentially life-threatening complication. Typhlitis should be added to conditions of the gastrointestinal tract that cause a psoas abscess such as Crohn's disease, diverticulitis, appendicitis, colorectal carcinoma, and appendiceal tumor.

Adolescent↗
PubMed1996

Recurrent septicaemia in a neutropenic patient with typhlitis.

We report a case where life threatening gram negative sepsis developed in a patient with CLL in association with post chemotherapy neutropenia on three occasions. Bacterial typhlitis or neutropenic enterocolitis, which is a well described entity of bowel necrosis seen in immunosuppressed patients, was demonstrated at colonoscopy and was the probable portal of entry of micro-organisms. After spontaneous resolution of the typhlitis, further chemotherapy has been given without recurrent sepsis. Typhlitis should be considered as a cause of recurrent septicaemia in neutropenic patients.

Enterocolitis↗
PubMed2002

Typhlitis complicating induction therapy in adult acute myeloid leukemia.

In a retrospective analysis of 161 consecutive adult patients with de novo acute myeloid leukemia undergoing induction therapy, including cytarabine, etoposide and anthracyclines, seven patients (4.3%) developed typhlitis. All presented severe neutropenia, fever, abdominal pain and tenderness within 16 days from starting chemotherapy (median 11 days; range 5-16). Three patients underwent surgery and survived, four were treated only with supportive therapy: two recovered and two died. In our experience early recognition of typhlitis and rapid recovery of the neutrophils are the most important determinants of the results of surgical and/or medical approaches. The management of typhlitis, a life-threatening condition, is controversial and depends on many factors characterizing each patient, which must be evaluated in collaboration between the surgeon and the hematologist.

Adolescent↗