Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.
Flecainide is an anti-arrhythmic drug with a narrow therapeutic index. Flecainide toxicity is rare, but the mortality is high. This case demonstrates the use of intravenous fat emulsion therapy in conjunction with intravenous sodium bicarbonate treatment for flecainide toxicity.A 50-year-old male with atrial fibrillation and taking flecainide 75 mg twice daily presented to Emergency Department after ingesting 1125 mg of flecainide, in a suicide attempt. An electrocardiogram (ECG) on arrival showed bradycardia, wide QRS complex, prolonged QTc interval. Treatment for flecainide poisoning with intravenous sodium bicarbonate was initiated. On day two, the patient had a cardiac arrest secondary to ventricular tachycardia. After successful defibrillation, the patient had persistent bradycardia and hypotension. Administration of a 20% lipid emulsion bolus, followed by continuous infusion for three hours, resulted in conversion to normal sinus rhythm. This case illustrates the successful treatment of flecainide toxicity with intravenous fat emulsion therapy. To our knowledge, this is the second case that used fat emulsion without concomitant extracorporeal life support. Due to its low prevalence and the fact the lipid emulsion is often used in conjunction with other treatments, there are no randomized clinical trials on the isolated efficacy of lipid infusion. The best treatment is unknown. Given its high mortality, early detection and treatment are paramount.
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