title: Neutropenic Enterocolitis: New Insights Into a Deadly Entity.
abstract: Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.
authors.affiliation: *The Ohio State University Wexner Medical Center †Nationwide Children's Hospital, Columbus ∥Cleveland Clinic, Cleveland, OH ‡Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA §Mayo Clinic, Rochester, MN ¶Children's Medical Center of Dallas #University of Texas Southwestern Medical Center, Dallas, TX **Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Taha
authors.initials: T
authors.lastname: Sachak
authors.forename: Michael A
authors.initials: MA
authors.lastname: Arnold
authors.forename: Bita V
authors.initials: BV
authors.lastname: Naini
authors.forename: Rondell P
authors.initials: RP
authors.lastname: Graham
authors.forename: Sejal S
authors.initials: SS
authors.lastname: Shah
authors.forename: Michael
authors.initials: M
authors.lastname: Cruise
authors.forename: Jason Y
authors.initials: JY
authors.lastname: Park
authors.forename: Lindsey
authors.initials: L
authors.lastname: Clark
authors.forename: Laura
authors.initials: L
authors.lastname: Lamps
authors.forename: Wendy L
authors.initials: WL
authors.lastname: Frankel
authors.forename: Nicole
authors.initials: N
authors.lastname: Theodoropoulos
authors.forename: Christina A
authors.initials: CA
authors.lastname: Arnold
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D044504:Enterocolitis, Neutropenic / Q000209:etiology / Q000401:mortality / Q000473:pathology* / Q000628:therapy; D005260:Female; D006801:Humans; D007422:Intestines / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D012307:Risk Factors; D014057:Tomography, X-Ray Computed; D014481:United States; D055815:Young Adult