INDIAN PEDIATRICS VOLUME31-IANUARY 1994 promotion of ORT usually get precedence 3. Rahaman MM, Aziz KMS, Patwari Y, over preventive measures which are likely to Munshi MH. Diarrheal mortality in two benefit the community in the long term. Bangladeshi villages with and without Innovative strategies for educating the community-based oral rehydration therapy. Lancet 1979, 2: 809-812. community about causes and methods of prevention of diarrhea need to be developed 4. Grant JP. The State of the World's Children. keeping in mind that many of the benefits Oxford University Press, Delhi, 1992, p 17. and practices are part of the existing culture of a particular society and are difficult to 5. Kumar V, Clements C, Marwah K, Diwedi change. P. Beliefs and therapeutic preferences of mothers in management of acute diarrheal REFERENCES disease in children. J Trop Pediatr 1985, 31: 109-112. 1. Kumar V, Kumar R, Datta N. Oral 6. Anand K, Lobo J, Sundaram KR, Kapoor rehydration therapy in reducing diarrhea- SK. Knowledge and practices regarding related mortality in rural India. J Diarrh diarrhea in rural mothers of Haryana. Indian Dis Res 1987, 5: 159-164. Pediatr 1992, 29: 914-917. 2. McCord C, Kielmann AA. A successful 7. Kumar V, Kumar R, Raina N. Impact of programme for medical auxiliaries treat- oral rehydration therapy on maternal beliefs ing childhood diarrhea and pneumonia. Trop and practices related to acute diarrhea. Doct 1978, 8: 220-225. Indian J Pediatr 1989, 56: 219-225.

Neutropenic Enterocolitis bidity and mortality among patients with hematologic malignancies and autopsy stud- with Acute Leukemia ies have documented a 10-12% incidence in patients dying of leukemia(2,3). Most of the early reports have labelled this condition as B.R. Agarwal a grave, preterminal event progressing to A.S. Sathe sepsis and death. However, the availability Z. Currimbhoy of modern antibiotics and supportive care

Neutropenic enterocolitis (NE) also termed From the Departments of Pediatric Hematology as typhlitis, nectrotizing enteropathy, ileo- and Oncology, B.J. Wadia Hospital for Chil- cecal syndrome, is a fulminant necrotizing dren, Institute of Child Health and Research process involving segments of large and small Centre, Parel, Bombay 400 012. intestine that occurs in the setting of agran- Reprint requests: Dr. Bharat R. Agarwal, Con- ulocytosis most commonly in patients with sultant Pediatric Hematologist and Oncolo- acute leukemia, lymphoma (induction or gist, 63, Candlii Nagar, Bandra (East), Bombay relapse), aplastic anemia, cyclic neutropenia 400 051. and in immunosuppressed organ transplant Received for publication: February 24, 1993; recepients(l). It is a major cause for mor- Accepted: May 25, 1993

57 BRIEF REPORTS with judicial surgical intervention has amylase was normal, SGOT - 65 IU/ml and improved the prognosis when instituted early SGPT - 44 lU/ml. Bone marrow examina- in the course of disease(4,6). tion showed remission pattern. PT and PTT were normal. With this clinical picture of a We report here a five-year-old leukemic bacterial infection, treatment was started with child with neutropenic enterocolitis devel- cefotaxime, tobramycin and metrogyl along oping during induction where the clinical with supportive packed cell transfusions and suspicion was confirmed on post mortem platelet concentrates. Failure of improve- examination. ment led to the suspicion of neutropenic Case Report enterocolitis though confirmation of this diagnosis by investigative methods like real A 5-year-old male child presented with time sonography could not be done. The fever, pallor and generalized lymphadenopa- child remained persistently febrile and thy of 8 days duration. His hematological continued to have a bloody diarrhea. A repeat findings revealed Hb 2.8 g/dl, total WBC blood culture was negative. On the thirty 1,900/cu mm, 26% polymorphonuclear cells, first post-induction day antibiotics were 74% lymphocytes and decreased platelet changed (ceftazidime and amikacin) and bowel numbers on smear. He was diagnosed to rest instituted. However, the patient suc- have acute lymphoblastic leukemia-L 1 cumbed on the 34th post-induction day. A morphology, with 65% PAS positive blasts post mortem performed showed remarkable on the bone marrow aspirate smears. His abdominal findings supporting the clinical chest X-ray and biochemical profile was suspicion of neutropenic enterocolitis. normal. Chemotherapy as per protocol POG- Esophagus and stomach were normal but 8602 was started with Vincristine, L-Aspar- small intestine and colon were edematous aginase, prednisolone and intrathecal che- with patchy areas of gangrene and hemor- moprophylaxis. Seven days after beginning rhage. Histopathological examination of these of induction, he had an abscess over the areas revealed transmural necrosis, crypt right hand dorsum following thrombophlebi- abscesses and fibrin thrombi. Bacterial tis at the venepuncutre site. colonization was seen. There was no evi- On 20th day, he complained of abdomi- dence of fungal colonisation or leukemic nal pain with mild fever which subsided infiltrates. Liver was normal on cut section. hence he was not hospitalized. Four days Discussion later he returned with moderate fever, persistent abdominal pain and diarrhea. On Neutropenic enterocolitis (NE), a fulmi- examination, the temperature ranged between nant necrotizing process is a well recognised 100-104°F, and there was severe stomatitis complication of neutropenia in patients dying with oral mucosal uncerations and bleeding. from hematologic malignancies especially Abdominal examination revealed generalized acture leukemia as indicated by various tenderness and tender hepatomegaly. Plain autopsy series(2,3). Moir and Bale reviewed X-ray of the abdomen appeared normal. Blood 50 necropsies of leukemic children and found count revealed a low absolute neutrophil count that necrosis of the colon was the primary of 460, with reduced platelets on smear. cause of death in 38%, cecal involvement in Blood culture showed no growth and stool 12% of cases. Other investigators have found culture grew E.Coli and Klebsiella. Serum similar results and it appears that many of

58 INDIAN PEDIATRICS VOLUME 31-JANUARY 1994

these cases are not clearly mainfested clini- treatment to support the patient until the cally and the diagnosis is made only at autopsy. return of circulating neutrophils and more NE is a diagnosis of exclusion in neutropenic cases are now successfully managed medi- patients with abdominal pain when cases with cally. In the 77 children with acute myeloid localized pain and those with a surgical cause leukemia on intensive chemotherapy reviewed for generalized pain are excluded(5,7). by Shamberger et al.(4), 25 had episodes of NE. Of these 25 patients 20 were managed NE includes a spectrum of involvement successfully without surgical intervention. of the gastro-intestinal tract varying from In the series review by Starnes et al.{5) of small bowel and colonic mucosal edema to the 58 patients with malignancies presenting transmural inflammation and infraction. with abdominal pain during episodes of Pathogenesis is obscure but appears to be neutropenia, 18 were diagnosed as neutropenic due to bacterial invasion following prolonged enterocolitis and 11 (60%) recovered with neutropenia and cytotoxic agent induced conservative therapy. The patients who died mucosal epithelial damage(4,5). The drug were those who failed to recover normal cytarabine has been implicated to produce granulocyte levels. necrosis of mucosal epithelium(4). Initial In conclusion, we believe that neutropenic symptoms mainly nausea, vomiting and enterocolitis is relatively common entity but abdominal pain with diarrhea may be vague, is often missed antemortem. In order to detect recurrent and nonspecific, hence indistin- it early, an ultrasound examination of all guishable from acute appendicitis, vincristine neutropenic patients with abdominal pain and/ or L-Asparaginase toxicity and pseudomem- or diarrhea should be undertaken. If bowel branous colitis. Full blown complex consists wall thickening is detected, appropriate broad of severe abdominal pain, fever, diarrhea - spectrum antibacterial therapy and bowel rest occasionally with malena, with sepsis fol- should be instituted. lowing within hours to days. Abdominal tenderness often more in the right lower Acknowledgement quadrant is seen, again not specific for the diagnosis of NE. In some series half $f the The authors are grateful to the Dean, patients had abnormal liver function tests(5). BJ. Wadia Hospital for children for permis- Plain abdominal radiographs showed a variable sion to publish this case. absence of gas shadows or ileus in approxi- REFERENCES mately 50 % of the cases reviewed by Stames et al. and only in the preterminal stages 1. Gootenberg JE, Abbondanzo SL. Rapid which is too late for any successful manage- diagnosis of neutropenic enterocolitis ment. Barium enema and colonoscopy are (typhlitis) by ultrasonography. Am J Pediatr hazardous procedures. Real time sonogra- Hematol Oncol 1987, 9: 222-227. phy has recently been established as a safe, 2. Moir DH, Bale PM. Necropsy findings in rapid and reliable method of diagnosing childhood leukemia emphasizing neutro- NE(1). The 'doughnut' like appearance of penic enterocolitis and cerebral calcifica- the small bowel indicating mucosal edema tion. Pathol 1976, 8: 247-258. directly reflects the pathology demostrated 3. Steinberg D, Gold J, Brodin A. Necrotizing at laparotomy. Recovery from NE hinges enterocolitis in leukemia. Arch Int Med on early institution of aggressive medical 1973, 131: 538-544.

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4. Shamberger RC, Howard JW, Delorey MJ, 6. Woodraw AB, Greenberg BR. Success- Levey RH. The medical and surgical ful medical management of neutro- management in children with acute myelo- penic enterocolitis. Cancer 1983, 51: genous leukemia. Cancer 1986, 57: 1551-1555. 603-609. 5. Starnes HF, Moore FD, Mentzer S, Osteen 7. Amromin GD, Solomon RD. Necrotizing RT, Sbeele GD, Wilson RE. Abdominal enteropathy a complication of treated pain in neutropenic cancer patients. Cancer leukemia or lymphoma patients. JAMA 1986, 57: 616-621. 1962, 182: 23-29.

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