Lehigh Valley Health Network Allentown, PA, United States
Rajesh Essrani, MD1, Anastasia Shnitser, 2 1Lehigh Valley Health Network, Allentown, PA; 2Lehigh Valley Health Network, Coopersburg, PA
Introduction: Neutropenic enterocolitis (NE), also known as typhlitis, is defined as transmural bowel wall inflammation which may progress to perforation and sepsis, in patients with severe neutropenia [1]. It has been described in immunosuppressed hosts including patients with leukemia, HIV, and in patients on chemotherapy. We present a case of sulfasalazine-induced NE in a psoriatic arthritis patient.
Case Description/Methods: A 24-year-old female with a newly diagnosed history of psoriatic arthritis presented to the hospital due to right lower quadrant abdominal pain, vomiting and decreased oral intake for the last 3 days. Her vitals were stable except pulse 109 and fever 102 0F. Physical exam was remarkable for Right lower quadrant tenderness and rebound tenderness. Blood work showed hemoglobin (Hb) 10.7 g/dL, Hematocrit (Hct) 34.0%, white blood cell (WBC) 0.70 thou/cmm, absolute neutrophil count (ANC) 1.1 thou/cmm, platelets 63 thou/cmm, sodium 140 mmol/L, creatinine 0.7 mg/dL, lactic acid 3.8 mg/dL. CT abdomen/pelvis with contrast showed a focal area of thickening involving the cecum with surrounding fat fussiness and few surrounding lymph nodes consistent with typhlitis. She was treated with intravenous hydration, pain medications, broad-spectrum antibiotics, and sulfasalazine was discontinued. She subsequently underwent colonoscopy which showed multiple superficial ulcerations, overlying thick slough, and significant mucosal erythema noted in cecum/ascending colon (Figure A). Pathology revealed bowel mucosa with moderate non-specific colitis. No crypts or dysplastic changes were seen. No convincing granuloma, amoebic trophozoite, or viral inclusion were noted. Her symptoms gradually improved and her neutropenia resolved within 3 days. She was subsequently able to tolerate oral intake and was discharged home.
Discussion: Neutropenic enterocolitis is a rare but dangerous complication of neutropenia of any cause. It should be high on the differential diagnosis of a patient with fever, abdominal pain, and on any immunosuppressive therapy. The resolution of the disease will depend on the recovery of leukocyte count and infection control. Early recognition and discontinuation of sulfasalazine are essential in preventing worse outcomes.
Figure: Figure A: Colonoscopy showing multiple superficial ulcerations, overlying thick slough, and significant mucosal erythema noted in cecum/ascending colon.
Disclosures:
Rajesh Essrani indicated no relevant financial relationships.
Anastasia Shnitser indicated no relevant financial relationships.
Rajesh Essrani, MD1, Anastasia Shnitser, 2. P1230 - Sulfasalazine-Induced Neutropenic Enterocolitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
