A 52-year-old woman was admitted as an emergency case, with fever and dizziness 3 days following her last cycle of chemotherapy consisting of cyclophosphamide, methotrexate and 5-fluorouracil. Her past medical history included asthma and ulcerative colitis which was in remission. The ulcerative colitis had been diagnosed in her 20s, and she took sulphasalazine and methylcellulose during treament. She had been treated for a ductal carcinoma of the breast (T2 N1 M0) by mastectomy and axillary clearance. Postoperatively, during the adjuvant chemotherapy, she had presented on previous occasions with neutropenic sepsis requiring fluid rehydration, granulocyte-colony-stimulating factor (G-CSF, Neupogen) and antibiotics. The last episode happened after penultimate cycle of chemotherapy. Diarrhoea was a feature of the whole chemotherapy period, but it was managed with simple medication without any need to be considered for admission.
On examination, the patient was febrile, tachycardic, hypotensive and clinically dehydrated. Systemic examination was unremarkable. Blood picture showed haemoglobin of 11.4 g/dl, white cell count 0.3×109/l, neutrophil count 0.11×109/l, platelets 120×109/l and normal renal functions. C-reactive protein (CRP) was 27. A working diagnosis of neutropenic sepsis following chemotherapy was made. Intravenous fluid support, antibiotics and G-CSF were administered as supportive treatment.
Two days later the patient developed cramping abdominal pains, bilious vomiting and diarrhoea. Abdominal examination showed a distended abdomen with minimal tenderness on deep palpation. Blood picture continued to show leucopenia with normal urea and electrolytes. The CRP had risen to 327. Plain abdominal x-ray showed multiple, small-bowel loops with features suggestive of ‘ileus’ (). The conservative management was continued with oral fluid restriction. A surgical opinion advised close monitoring of her condition.
Plain abdominal film showing prominent small-bowel loops.
Five days after admission, the patient passed a long cast of approximately 135 cm (). Physical examination showed it to be a complete luminal cord like structure resembling an intestinal cast (). A CT scan of abdomen showed diffuse small-bowel thickening with a normal-looking large bowel. Histology of the specimen showed it to be a small intestinal cast, having undergone extensive coagulative necrosis (). Microbiological examination of the cast revealed florid growth of fungal infection ().
(A&B) Passage of intestinal cast, following chemotherapy.
(A) Intestinal cast laid open. (B) Transverse section of the intestinal cast.
(A&B) Section of the small-bowel cast showing extensive fibrinous exudate and coagulative necrosis. (A) Intense neutrophilic infiltration is seen (arrows). (B) Low power showing complete transverse section of the cast.
Intestinal cast section showing heavy infestation with fungal elements.