A 54 y.o. with metastatic squamous cell ca of the tongue presents with RLQ pain.
What is in the RLQ?
Our patient had typhlitis or neutropenic colitis with a wbc of 200.
The name comes from the Greek word typhlon or cecum and it is an inflammatory condition involving the cecum in neutropenic patients. It was first described in children with leukemia but can occur in any immunocompromised patients including lymphoma, aplastic anemia, organ transplant patients and patients with AIDS.
It is diagnosed on the CT when the colonic wall Is greater than 3 mm or there is fat stranding around the cecum.
Cecal wall thickening seen more easily with contrast in typhlitis
The cause of this neutropenic enterocolitis is not known but it occurs in 5% of adult neutropenic patients. The cecum is often affected perhaps because of its poor blood supply and its ability to distend. Microorganisms such as clostridium, pseudomonas, E coli.and Klebsiella have been found in areas of necrotic bowel suggesting it is an infectious process in an immunocompromised host. It has also been reported in nonneutropenic adults following ingestion of food containing C. Perfingens type A.
Thrombosed R ovarian vein, shown non enhancing with arrows and open arrow showing fat stranding; another cause of RLQ pain.
The differential for RLQ pain is broad and includes hydrosalpinx, ovarian cyst, renal stones, diverticulitis, Crohns disease, epiploic appendagitis, ischemic bowel, cancer and Yersinia, the classic boards question. Ileocolitis has other infectious causes including salmonella, c diff and Campylobacter.
Our pt was treated with filgrastim( a white cell stimulator), and cefepime with flagyl. He was discharged in 4 days. The mortality in the literature for the condition is 50%.
Yu J, fulcher A, Turner M, Halvorsen R. Helical CT Evaluation of acute right lower quadrant pain: part I, common Mimics of appendicitis.Am J roentgenol 2005;184(4):1136-1142.
Sobel J, Mixter CG, Kolhe P. et al. Necrotizing enterocolitis associated with clostridium perfringens illness at a state psychiatric hospital—Louisiana, 2010. MMWR Morb Mortal WKly Rp 2012;61:605.
Mullassery D, Bader A, Battersby A, et al. Diagnosis, incidence, and outcomes of suspected typhlitis in oncology patients—experince in a tertiary pediatric surgical center in the UK. 2009 Joural of Pediatric Surgery 44:381-385.