The Right Lower Quadrant in the Wrong White Count

A 59-year-old woman with metastatic poorly differentiated neuroendocrine carcinoma of the pancreas is on day 12 after cycle 2 of cisplatin and etoposide. Her course has been complicated by febrile neutropenia, and empiric cefepime monotherapy was started 48 hours ago when she first spiked a fever; blood cultures drawn at that time remain negative. She had been afebrile for a day, but overnight she developed worsening crampy abdominal pain that has localized to the right lower quadrant, along with six episodes of non-bloody diarrhea and new nausea. She has no vomiting, no recent antibiotic exposure beyond the chemotherapy and cefepime, and no sick contacts.

On examination she is ill-appearing. Temperature 38.9 °C, heart rate 112, blood pressure 104/64 mmHg, respiratory rate 20. The abdomen is soft but markedly tender in the right lower quadrant with voluntary guarding; there is no rigidity and no rebound. Bowel sounds are hypoactive. Laboratory studies: WBC 0.4 k/mcL with an absolute neutrophil count of 180 cells/mcL, hemoglobin 9.8 g/dL, platelets 42 k/mcL, serum creatinine 1.1 mg/dL, lactate 2.1 mmol/L. A stool Clostridioides difficile nucleic acid amplification test is negative. Blood cultures are redrawn.

Because she remains febrile on cefepime and has developed focal right lower quadrant tenderness during profound neutropenia, a contrast-enhanced CT of the abdomen and pelvis is performed. It demonstrates marked circumferential wall thickening of the cecum and terminal ileum measuring up to 14 mm, surrounding peri-cecal fat stranding, and curvilinear foci of gas within the dependent cecal wall consistent with pneumatosis intestinalis. There is no portomesenteric venous gas and no free intraperitoneal air or fluid. The appendix is separately identified and normal. The imaging is shown below.