Typhlitis

Case contributed by Michael P Hartung
Diagnosis almost certain

Presentation

Metastatic endometrial cancer on chemotherapy, with worsening abdominal pain

Patient Data

Age: 60 years
Gender: Female

Day 1

ct

Thickening/submucosal edema of the cecal wall, new from prior. Mild haziness of the adjacent pericolonic fat. 

Moderate left hydroureteronephrosis appears similar to prior, with transition to normal caliber ureter at the left pelvic sidewall implant. 

Similar several irregular retroperitoneal/periaortic lymph nodes. Left periaortic node may invade the left renal vein as it appears attenuated in this region. Slight enlargement of left psoas metastasis. 

Diffuse stranding and enlargement of the right external iliac vein through the common femoral and visualized femoral and profunda femoral veins. Increased asymmetric edema of the right lower extremity. The vein appears to be obstructed at the level of the enlarged right pelvic sidewall lymph node.

IMPRESSION:

Comparison: 2 mth previously

ct

Normal appearance of the cecum. Mixing artifact versus non-occlusive thrombus in the right external iliac, common femoral, and visualized femoral vein. Right lower extremity subcutaneous edema and right pelvic sidewall implant favor that this is true thrombus. Findings of metastatic disease are similar with the exception of smaller size left psoas muscular metastasis. 

Case Discussion

This is a very complicated case given the combination of acute, subacute, stable, and progressive findings. Sorting through case like this can be very time consuming, and it can be difficult to be organized. 

The acute finding is new submucosal thickening and mild inflammation involving the cecum. In the setting of endometrial cancer on chemotherapy, this is highly characteristic of typhlitis. This finding is relatively subtle, but new from prior. Typhlitis occurs in immunocompromised patients when there is intramural bacterial invasion. They are at risk for ischemic necrosis and perforation if untreated. This was managed with antibiotics and resolved on the follow-up scan.

The subacute finding is complete thrombosis of right lower extremity veins secondary to occlusion by a right pelvic sidewall implant. This was very subtle on the scan from two months prior, but likely starting given the presence of subcutaneous edema in the right lower extremity. Thrombosis was confirmed with ultrasound following the CT.

Stable findings include obstruction of the left ureter by left pelvic sidewall lymph nodes, and irregular periaortic adenopathy which likely invades the left renal vein.

Progressive findings include enlargement of the left psoas intramuscular metastasis.

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