Spontaneous Intestinal Perforation: An Atypical Presentation of Neutropenic Enterocolitis—A Case Report

Background. Neutropenic enterocolitis is one of the most common gastrointestinal complications seen in patients who are receiving chemotherapy for leukemia. Severe neutropenia is the main underlying factor of this pathology. It is characterized by fever and abdominal pain. Case Presentation. Herein, we report a case of neutropenic enterocolitis which presented with intestinal perforation in an afebrile patient who was diagnosed with acute lymphoblastic leukemia and was receiving induction chemotherapy. Conclusion. We aimed to emphasize the importance of enterocolitis and increase awareness against such severe complications which could have unexpected presentations. 1. Introduction Neutropenic enterocolitis or typhlitis is characterized by fever and abdominal pain [1]. It is seen primarily in severely immunosuppressed and neutropenic patients with leukemia [1, 2]. Herein, we report a case of neutropenic enterocolitis which presented with spontaneous intestinal perforation in an afebrile patient who was receiving induction chemotherapy for acute lymphoblastic leukemia. 2. Case Our patient was a 4-year-old girl diagnosed with common acute lymphoblastic leukemia. She was on remission induction phase of chemotherapy consisting of prednisolone (60？mg/m2/day; 1–28 days; from day 29 tapered to withdrawal over 9 days), vincristine (1.5？mg/m2/day; days 8, 15, 22, and 29), L-asparaginase (5,000？U/m2/day; days 12, 15, 18, 21, 24, 27, 30, and 33), daunorubicin (30？mg/m2/day; days 8 and 15), and intrathecal methotrexate (dosage adjusted to age). She was in deep neutropenia since she was admitted to hospital. On the day 27 of chemotherapy, she developed fever. Her leukocyte count was 0.5？？× 109/L and absolute neutrophil count was 0.0？？× 109/L. C-reactive protein (CRP) was 2.6？mg/dL. Her renal, liver function panel, and urinalysis were normal. Blood from the port catheter and pheripheral vein was sampled for cultures and then broad-spectrum antibiotics were initiated empirically and chemotherapy was postponed. On her physical examination there was not any focus on fever. Her oral mucous membrane was normal. She did not have oral mucositis. Her liver and spleen were not palpable. She did not have abdominal tenderness, distension, or any other clinical findings related to abdominal distress. Her oral intake was good. She did not have vomiting and her stool was normal. Thorax radiograph was normal. Her fever lasted for two days. On the 3rd day of antibiotics her fever resolved; on the 4th day she was still afebrile but she developed abdominal pain. Physical examination