Predictors of Mortality in Neutropenic Enterocolitis Among Children and Young Adults with Acute Myeloid Leukemia in Low Middle Income Countries

Background: Neutropenic enterocolitis (NEC) is a life-threatening disease with substantial morbidity and mortality, seen primarily in patients with hematologic malignancies. The frequency of NEC has increased with the widespread use of chemotherapeutic agents such as the taxanes, which cause severe gastrointestinal mucositis. Methods: This was a retrospective study at the National Cancer Institute, Cairo University. The computerized records were screened for ultrasound or computerized tomographic scan requests for abdominal pain for all Acute myeloid pediatrics inpatients (2012-2016). Retrospective case analysis was used to collect clinical data for patients with features of NEC. D 30 Mortality was reported. Results: The incidence of NEC among our inpatients was 24% (49/203). Forty-Three children had radiologically confirmed Typhlitis, and 6 had clinical features alone. Most (93%) patients were profoundly neutropenic (ANC less than 100). All of the patients received conservative management. All of them needed ICU admission. Eighteen children had a variable period of bowel rest, including 12 patients who were supported with total parenteral nutrition. Three patients had laparotomy that revealed extensive colonic bowel necrosis (1), perforated bowel loop (1), and a perforated appendix (1). Two out of three cases of Laparotomy were diagnosed with Mucormycosis. 30-Days mortality was 44.8% (22/49). Relapsing Typhlitis in subsequent courses was observed in 6/27 (22%) patients. Fulminant gram-negative sepsis without surgical intervention was the leading cause of death in this cohort. NEC related mortality was significantly higher among patients receiving high-risk protocol with more intensive chemotherapy and in patients with other Co-Morbidities [chest infections and/ or Cardiac affection] with a P-value of 0.005 and 0.037 respectively. Also, mortality was increased among patients with more than 2 presenting clinical symptoms with a P-value of 0.01. Conclusion: Although surgical intervention should be reserved for specific complications, its delay increases the incidence of NEC related mortality. Though rare, fungal infection should be suspected especially in cases with worsening signs of typhlitis despite broad antimicrobial coverage. Early management and better supportive care of underlying Co-morbid conditions can decrease NEC related mortality.