Opening Aeolus' Bag of Winds: Acute Abdominal Pain in a Severely Immunosuppressed Patient

BackgroundNecrotizing enterocolitis (NE) is a necrotizing disease mostly of the ileocecal region. It is a severe and potentially life-threatening complication that can affect patients undergoing chemotherapy for lymphoma. We analyze a case of NE that occurred in a patient with non-Hodgkin's lymphoma during chemotherapy with concurrent HIV infection.Case ReportWe present a case of a 37-year-old woman who was admitted to our emergency department because of acute abdominal pain. Her medical history included HIV infection and B-cell immunoblastic lymphoma. For the latter, the patient was receiving rituximab cyclophosphamide hydroxydaunorubicin oncovin vincristine prednisone (R-CHOP) regimen. A complete blood count showed a low leukocyte count (40/mm³) and a low neutrophil count (32/mm³). An exploratory laparotomy with midline incision was performed. Intraoperatively, the cecum and the proximal part of the ascending colon were found to be edematous with the mesocolon being extremely gelatinous without macroscopically identified ischemia. Histopathology revealed a nonspecific infarction necrosis of the bowel wall with multiple ulcerations in the cecum, but no evidence of major vessel thrombosis. The patient had an uneventful postoperative course and was discharged in good condition on the 10th postoperative day.Why Should an Emergency Physician Be Aware of This?To our knowledge, this is the first reported case of NE in a patient with acquired immune-deficiency syndrome who developed the syndrome during an episode of severe neutropenia and was treated surgically. The decision to operate should be balanced between the clinical and laboratory status as well as the operative risk. Physicians should be aware of this complication of chemotherapy, especially in severely immunosuppressed patients, because it could be triggered just by an episode of neutropenia.