Yezan Abderrahman, MD
Pediatric Critical Care Fellow
University of Iowa Hospital and Clinics
Iowa City, IA, United States
Disclosure information not submitted.
Kristen Brown, ARNP
Nurse Practitioner, Pediatric Critical Care
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Aditya Badheka, MD, MS
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospital and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Madhuradhar Chegondi, MD
Clinical Associate Professor, Division of Pediatric Critical Care Medicine
University of Iowa Stead Family Childrens's Hospital
Iowa City, IA, United States
Disclosure information not submitted.
Title: Clostridium Septicum Sepsis and Neutropenic Enterocolitis in A Child with Acute Lymphocytic Leukemia
Case Report Body: INTRODUCTION: Clostridium Septicum infection is rare in children. Patients with neutropenia are more susceptible. Patients with this infection are also prone to developing neutropenic enterocolitis and intra-abdominal complications. Mortality can be significant, especially with gastrointestinal tract involvement.
Description: We present a 2-year-old male with recent diagnosis of B-cell acute lymphocytic leukemia (ALL) who was started on induction chemotherapy with Vincristine and Dexamethasone. On day 15 of induction, while on the oncology floor, he developed fever, bloody diarrhea and became tachycardic (180 bpm), and hypotensive (60/40 mmHg). Stool PCR was positive for Clostridium Difficle. He was transferred to the PICU for concerns of shock. On physical examination, patient’s abdomen was markedly distended with diffuse tenderness and absent bowel sounds. Abdominal X-ray demonstrated extensive pneumatosis intestinalis and blood count was remarkable for severe neutropenia, ANC 97/mm3. He was subsequently intubated for hemodynamic instability. Blood culture was positive for Clostridium Septicum and C-Reactive protein (CRP) peaked at 30.7 mg/dL. He also showed signs of coagulopathy secondary to ongoing sepsis with PT 22, INR 2.2, and PTT 96 seconds. Due to worsening hemodynamic instability he was placed on ECMO watch. Additionally, He was started on metronidazole, cefepime and daptomycin and subsequently switched to linezolid and piperacillin/tazobactam for infection source control. His clinical status improved and was subsequently transferred to the oncology floor after 10 days. Two weeks later he returned to our unit with high grade fever (39 C), tachycardia, and worsening abdominal distension. Abdominal X-ray revealed free air in the abdomen. Exploratory laparotomy revealed 2 colonic perforations in the transverse and sigmoid colon, respectively. Surgical repair with diverting loop ileostomy was done. Patient recovered well and was later discharged.
Discussion: Our case shows an association between Clostridium Septicum sepsis and enterocolitis in the setting of chemotherapy-induced neutropenia. Our experience shows that patients can get acutely ill with rapid decompensation. It is imperative to start broad spectrum antibiotics, deliver aggressive resuscitation, and intervene surgically as indicated.