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Adult Typhilitis Associated With Lymphoma and Steroid Use
Anderson, BD, D.O., Welzbacher, K, D.O.
Kent Hospital, Department of Emergency Medicine, Warwick, RI
INTRODUCTION: Typhilitis is a necrotizing inflammatory condition usually involving the
terminal ileum or ascending colon. Typhilitis was first described in children with leukemia
and severe neutropenia. It most commonly occurs in the setting of immunocompromise,
chemotherapy, and or chronic steroid use with a mortality rate approaching 50%.
CASE: A 69-year-old white male presents to the Emergency Department with the acute
onset of diffuse abdominal pain progressive for six hours. He describes a moderate to
severe pain that worsens with minimal movement. He reports associated subjective
fever, four episodes of nonbloody diarrhea with nausea, and mild shortness of breath.
He denies trauma to his abdomen. He reports mild episodes of similar abdominal pain
over the past year. The patient was suspected to be experiencing abdominal pain upon
initial evaluation likely from perforated appendicitis or perforated small bowel obstruction
with sepsis.
Portable chest X-ray, laboratory studies, and an abdominal flat and upright X-ray
series were initially ordered. Following review of his laboratory findings, his profound
neutropenia was thought to be due to profound sepsis. The patient was placed on
monitoring and given oxygen by nasal cannula. Intravenous (IV) access was
established and the patient was given empiric broad spectrum antibiotics. Morphine pain
medication was additionally given along with Acetaminophen for fever and fluid
resuscitation was initiated with normal saline(NS). After reviewing the nonspecific
findings on the abdominal X-ray series with the consulting surgeon a CT of the abdomen
with oral and IV contrast was ordered to better define the diagnosis and assist with
planning a surgical procedure.
Computerized Tomography(CT) results revealed evidence small bowel perforation at
the distal ileum with ileocolonic wall thickening suggestive of bowel necrosis and
typhlitis. The consulting surgeon took the patient to the operating room following stress
dose steroid administration for possible adrenal insufficiency. A small bowel resection
was performed and an ileostomy was created. He remained in the Intensive Care Unit
for two days and was discharged to a rehab facility following a 10 day hospitalization.
DISCUSSION: This perforation was thought to occur from a process known as typhilitis,
a necrotizing inflammatory condition usually involving the terminal ileum or ascending
colon. The exact cause of typhilitis remains unknown however the mechanism is thought
to be due to a combination of inflammation and possible acute infection
(Cytomegalovirus, Pseudomonas aeruginosa), mucosal hemorrhage, and possible
neoplastic infiltration.
Typhlitis is usually seen at the neutropenic nadir, usually 7 to 14 days following
chemotherapy. These patients will present with abdominal pain, usually right lower
quadrant in nature, and fever. Differentiating typhlitis from other infections such as
appendicitis is nearly impossible without imaging.
The cause of our patient’s typhilits is unclear; however he was at great risk given his
history of chronic steroid use for ongoing ileal inflammation, his relative
immunocompromise, and his prior history of chemotherapy.