Case of the Month - March 2001

Winner Announced
The Palm handheld for the April Contest goes to third year resident, Dr. Mario Laguna. One entry we received for the April case that was not included in Dr. Buetow's list of differentials was intususseption. Dr. Buetow explains the typical findings in intususseption as well.

March 2001 Answer

Prepared by:
Evan Kransdorf, Medical Student, and
Peter Buetow, M.D.

Clinical History:
74 year-old Hispanic male with history of myelodysplasia and pancytopenia. Presents with five days of vomiting, diarrhea, and right lower quadrant pain.

Figure 1	Figure 2
Figure 1 Axial CT scan with contrast demonstrates: circumferential cecal wall thickening, pericolic inflammatory changes, low attenuation in wall = necrosis / edema Figure 2 A more caudal axial CT scan with contrast also demonstrates: circumferential cecal wall thickening, pericolic inflammatory changes, low attenuation in wall = necrosis / edema

Discussion:

Typhlitis is a necrotizing inflammation of the cecum. It is seen in immuno-compromised hosts and was first described in childhood leukemia. It is also seen in cases of lymphoma, aplastic anemia, renal transplants recipients, and AIDS. It typically shows rapid progression to transmural necrosis and perforation (see gross specimens C and D). It usually occurs during periods when the immune system is recovering from its nadir.

Figure 3	Figure 4
Figure 3 Gross specimen of the cecum shows exudative hemorrhagic necrosis of the mucosal surface (arrow) and transmural thickening. Figure 4 The serosal surface of the cecum shows the exudative surface with transmural inflammation and hemorrhage.

Treatment includes high dose antibiotics and IV fluids. Steroids have been used as well. These medical therapies have lower mortality than surgical resection, which is reserved for severe or unresponsive cases.

Radiographic findings include circumferential cecal wall thickening, pericolic inflammatory changes, low attenuation in wall due to necrosis, and edema. In some cases, pericolic fluid and pneumatosis may be seen.

The differential diagnosis includes a number of disorders that can usually be distinguished based on the clinical history. These include:

leukemic infiltrates
appendicitis
ruptured R sided diverticulum
intramural hemorrhage / ischemia
segmental pseudomembranous colitis
Crohn’s Disease
Ruptured cecal carcinoma

Diagnosis:
Typhlitis