A Fulminant Enterocolitis

Abstract

A 54-year-old woman was referred to the intensive care unit (ICU) for shock and abdominal pain. There was a 4-month history of localized breast cancer treated by surgery and chemotherapy. Her performance status was not altered. The last course of chemotherapy (adriamycin and taxol) had been administered 10 days before. Abdominal pain, located initially in the right lower quadrant, and chills began 12 hr before ICU admission. Four hours after abdominal pain occurrence, the patient was oriented and had no circulatory or respiratory distress but presented with mild abdominal discomfort. There was neither diarrhea nor vomiting and nausea. Rectal temperature was 40 • C, and heart rate was 115 bpm. The abdomen was painful and slightly distended, without tenderness. Bowel sounds were rare and rectal examination was negative. White cell count was 200/µl. An abdominal x-ray and an ultrasound examination did not disclose any abnormalities. Blood cultures were drawn and intravenous ceftazidime (2 and 6 g/day) plus amikacine (25 mg/kg once a day) was started. Four hours before ICU admission, mild hypotension occurred, responding initially to administration of intravenous fluid. Two hours before ICU admission, confusion, recurrence of hypotension, and increased abdominal pain motivated ICU referral. The patient was obtunded but answered questions. Blood pressure was 81/36 mm Hg, and pulse rate was 126 bpm. Mottling was observed on the knees and the abdominal wall. Intravenous isotonic saline, norepinephrine, piperillin/tazobactam, 4 g/qid 6 hr, and ornidazole, 1 g/day, were administered. Abdominal computed tomography scan showed pneumoperitoneum and the presence of gas in the colonic wall and portal vein (Fig. 1). Emergent laparotomy were performed. The abdominal cavity contained serosanguinous liquid, and there was extensive digestive necrosis involving the last meter of the ileum, the right colon, and the terminal part of the left colon. Despite supportive care and large bowel resection, the patient died 36 hr after ICU admission.Histological examination showed necrosis of the wall of the ileum and right colon. Bacteriological examination showed Gram-positive rods. Culture yielded Clostridium septicum, producing lethal toxin for mouse. PCR amplification detected the gene encoding for the lethal toxin of C. septicum. C. septicum is known to be one of the agents Fig. 1 Abdominal computed tomography scan showing pneumoperitoneum and the presence of gas in the colonic wall and portal vein Springer