Friday, 12 August 2016

Abdominal Pain in an Immunocompromised Patient: A Case Report of Typhlitis



Here we present the case of a 52-year-old female with a known past medical history of non-resectable mixed adenocarcinoma and small-cell lung cancer with metastatic disease to the brain who presented to the emergency department with complaints of sharp, stabbing abdominal pain predominantly in the right lower quadrant and suprapubic region, progressively worsening since earlier that evening. She also experienced several episodes of nonbloody nonbilious vomiting as well as nonblood nonmelenic mucousy diarrhea. Remaining pertinent medical and surgical histories include seizure disorder, a left-sided thoracotomy with an aborted lung resection, resection of a metastatic lesion in the brain, and placement of a right-sided subclavian port. Of note, she was recently admitted to our hospital for pneumonia and bilateral lower extremity cellulitis. She reported no drug or food allergies, and social history is negative for tobacco, alcohol, or illicit drug abuse (she quit smoking about 2 years ago). She had been on chemotherapy and radiation therapy for the primary lung cancer, however was forced to stop the treatments about 9 months ago secondary to development of pancytopenia and myelodysplastic syndrome. 

On physical examination, she was nontoxic but uncomfortable appearing; initial vital signs are as follows: blood pressure 112/52 mmHg, pulse rate 128 beats/minute, breathing 22 respirations/minute, an oral temperature of 98.1 degrees, and saturating 98% on ambient air. She was cachectic (bodymass index of 20.6), with bitemporal wasting and dry mucous membranes. Cardiopulmonary exam is significant for tachypnea and tachycardia. Her abdomen was soft, nondistended, with severe tenderness to minimal palpation predominantly in the right lower quadrant but without any peritoneal signs, and normal bowel sounds. The rectal examination was deferred by the patient. The remaining physical examination was unremarkable, including resolved lower extremity cellulitis. Given her significant presentation and past medical history, an extensive work-up was undertaken specifically focused on inflammatory markers, cultures, and imaging of the abdomen. Pertinent findings were as follows: leukopenia (0.5/uL; reference range: 3.7-10.5), neutropenia (22.8%; reference range 37.8-85.8%) with an absolute neutrophil count of 100/uL, absolute lymphocytes count of 100/uL (reference range 800- 3,500/uL), and absolute monocyte count of 200/uL (reference range: 300-900/uL), thrombocytopenia (57,000/uL, reference range: 150,000-400,000), a lactic acidosis (2.3mmol/L, reference range: < 2), and c-reactive protein 44.1mg/dL (reference range < 0.5). Her urinalysis, electrolytes, liver function (except for a mild indirect hyperbilirubinemia), coagulation panel, lipase and cardiac biomarkers were within normal limits. Given the patient’s recent hospitalization, course of antibiotics, and presentation with abdominal pain and diarrhea, metronidazole was empirically initiated with a high suspicion for Clostridium difficile.

Computed axial tomography of the abdomen and pelvis (unenhanced given her poor baseline creatinine clearance and inability to tolerate oral intake; images 1 and 2) revealed a fairly significant amount of thickening of the terminal ileum, cecum and proximal ascending colon. There was marked surrounding stranding and a mild amount of pelvic free fluid (simple density), tracking presumably from the right lower quadrant. The appendix was normal in appearance, without evidence of pneumatosis or free air. Cefepime was added, and after consultation with the Infectious Disease service a weight-based dose of vancomycin was started. The patient’s hemodynamic parameters remained stable throughout her stay in the emergency department (except for persistent tachycardia; she never became hypotensive or required pressor support). Given her significant presentation, the General Surgery service was consulted emergently as well, and she was placed under the care of the Critical Care service for continued management.

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