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A previously fit 23 year old adult male who presented with a sudden onset of profound autonomic neuropathy, for which no cause could be found, is described. The patient subsequently developed ischaemic enterocolitis that ultimately necessitated colectomy and subtotal enterectomy. Potential neural and humoral mechanisms are discussed.
OBJECTIVE: To evaluate the features of clinical presentation of neonatal necrotizing enterocolitis and its associated factors. METHODS: Retrospective study of the cases of neonatal necrotizing enterocolitis (n = 56) diagnosed at Neonatal Intensive Care Unit Lagoa (NICU), between December 1986 and July 1992. Diagnosis and stages of the disease followed the modified Bell's criteria. Diagnosis and follow-up of all cases were evaluated. The cases of enterocolitis - degrees II and III (n = 44) - were subsequently selected and compared to a case-control group (n = 44), selected according to birthweight (+/- 250 g) and hospitalization period (+/- 2 weeks). The statistically significant analysis was considered as p < 0.05. RESULTS: Out of 2,447 newborns admitted to the NICU, 56 (2.3%) presented enterocolitis. Mean weight was 1908.5 g; mean gestational age was 35 weeks and 1 day; mean period for diagnosis was 10.7 days; 51 (91.1%) patients were fed before diagnosis; 18 (32.1%) needed urgent surgery; nine (16.9%) hemocultures were positive; 10 (17.8%) patients died. Four clinical standards were observed: fulminant, acute with pneumatosis, insidious and suspect. Comparatively to the case-control group, three factors were significantly associated with enterocolitis: apnea (p = 0.045), rapid increase of food intake (< 20 ml/kg/day) - (p = 0.048) and presence of infectious agent (p = 0.000). CONCLUSIONS: Significant factors associated with enterocolitis were occurrence of apnea, rapid increase of food intake and identification of the infectious agent.
Infants discharged from neonatal intensive care units (NICUs) often face a long journey of chronic illness, family stresses, and financial burdens. Health care professionals involved in acute care need to be aware of the far-reaching repercussions of neonatal illness. This report presents a case study of a low-income, single mother from a rural community and her son, a neonatal intensive care unit (NICU) graduate post-extracorporeal membrane oxygenation (ECMO) and post-necrotizing enterocolitis (NEC) discharged with a gastronomy tube (g-tube) and failure to thrive (FTT), from his birth to 10 months of age. Family-focused interventions aimed at improving growth and developmental delays and providing family support will be discussed.
BACKGROUND: This case series with an accompanying review of the literature describes neutropenic enterocolitis as a complication of high dose chemotherapy with stem cell rescue in patients with solid tumors. METHODS: Neutropenic enterocolitis is documented in two patients undergoing autologous stem cell transplantation. A review of MEDLINE from 1970 to the present was performed to delineate the prior related disease settings in which this condition has been described. The nature of the clinical syndrome and controversies regarding management are discussed. RESULTS: The authors report two patients who each received autologous stem cell transplantation for the treatment of a solid tumor. Both patients presented with progressive abdominal pain, signs of peritoneal irritation on examination, and pneumatosis intestinalis. In the first case, the syndrome developed rapidly over several hours, requiring emergent surgical intervention during the period of postchemotherapy nadir. In the second case, the patient developed a slowly progressive clinical picture that was managed successfully with medical therapy alone. A review of the literature suggests that neutropenic enterocolitis arises due to drug-induced bowel wall mucosal injury followed by superinfection with colonic and opportunistic organisms. Surgical intervention potentially is beneficial in patients who develop an acute syndrome that is unresponsive to antibiotic and supportive therapy. Those patients who can be stabilized with medical management often will recover once reengraftment occurs. CONCLUSIONS: Neutropenic enterocolitis is described in two patients undergoing autologous stem cell transplantation for solid tumors. The management of this life-threatening complication is controversial and governed by the nature of the clinical presentation.
Necrotizing enterocolitis in adults is a rare disease and, in the past, has been associated with nearly uniform mortality. In recent years, necrotizing enterocolitis, now termed neutropenic enterocolitis, in adults has become more prevalent as a complication of aggressive systemic chemotherapy. In this report, we discuss two cases of neutropenic enterocolitis secondary to the administration of systemic chemotherapy in adult cancer patients: one with lung carcinoma, the other with leukemia. Both patients were successfully treated with early surgical intervention for resection of all necrotizing enteric lesions, and subsequent aggressive critical care support. Our experience suggests that early surgical intervention in adult patients with intestinal necrosis due to chemotherapy is essential to avoid mortality from this condition. Given the widespread, aggressive use of systemic chemotherapy in the neoadjuvant setting, patients at risk for this potentially lethal complication of neutropenic enterocolitis are increasingly common.
Acute abdominal abnormalities are relatively uncommon during the treatment of leukemia. Over a 22 1/2 year period, acute abdominal abnormalities were diagnosed in 22 of 412 patients (5.3 percent) with acute leukemia and in 9 of 343 patients (2.6 percent) with chronic leukemia. Five patients with acute leukemia and two patients with chronic leukemia were treated medically, and all died within 1 week of diagnosis. Operative mortality decreased from 50 percent during the first half of the study period to 12.5 percent during the last half and was not related to the preoperative white blood cell count, platelet count, age of the patient, type of leukemia, or state of relapse or remission. Postoperative survival averaged 23 months in the patients with chronic leukemia and 5 months in those with acute leukemia, approximating the length of survival of patients with uncomplicated acute or chronic leukemia. Indications for operation in patients with leukemia are the same as for other patients and should be based on careful physical examination.
Platelet-activating factor (PAF) is an endogenous phospholipid which has been implicated as a mediator of allergic and inflammatory processes. It is synthesized and released by neutrophils, platelets, macrophages, monocytes, basophils and endothelial cells, and is a potent platelet-aggregating agent, a vasodilator, increases vascular permeability, stimulates neutrophil aggregation and degranulation and induces release of lysosomal enzymes. A role for PAF in the hypotension associated with endotoxin shock and in necrotizing enterocolitis has recently been suggested. As there is an association between septic shock and acute gastric damage, we propose that PAF is an endogenous mediator of ulceration in the stomach. Indeed, as reported here, intravenous (i.v.) infusion of PAF to rats, at doses of 20-200 pmol per kg per min, resulted in the formation of extensive haemorrhagic erosions in the gastric mucosa. The ulcerogenic actions of PAF are not attributable solely to its hypotensive actions and were not mediated via effects on platelets or cyclooxygenase products, nor via histamine H1, H2 or alpha-adrenergic receptors. PAF is the most potent gastric ulcerogen yet described and its endogenous release may underlie or contribute to certain forms of gastric ulceration.
A case history of a fatal neonatal infection caused by Salmonella enteritidis group D is reported. The baby deteriorated rapidly at 24 hours after birth with clinical signs and symptoms of an acute abdomen. Bloody diarrhea led to a tentative diagnosis of midgut volvulus or necrotizing enterocolitis. Autopsy and bacteriologic investigation revealed sepsis by S. enteritidis group D. The same organism was found in cultures taken from stool and vaginal swabs from the mother. This clearly confirmed transmission of the infection during delivery.
The relationship between type 1 pili-associated adhesion and invasion to HeLa cells by Salmonella braenderup and S. typhimurium was studied. When the clinical isolates of these strains were grown in L-broth, they showed both type 1 pili formation and mannose-sensitive adhesion to HeLa cells. On the other hand, the type 1 pili-defective mutants, which were obtained either by repeated subcultures on L-agar plates or by the transposon Tn1-insertion mutagenesis of the S. braenderup and S. typhimurium strains, concomitantly lost mannose-sensitive adhesion to HeLa cells. When the HeLa cells were incubated with Salmonella, the type 1 piliated strains invaded the HeLa cells with much higher infection rate than did the type 1 pili-defective strains. The invasion of type 1 piliated strains to HeLa cells was markedly inhibited in the presence of D-mannose. The infectivity of the strain, which lost type 1 pili but still had mannose-resistant adhesion, was slightly higher than that of the strains defective in both mannose-sensitive and mannose-resistant adhesion. These results suggested that type 1 pili have a role in enhancing the invasion of S. braenderup and S. typhimurium to HeLa cells.
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