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Acute necrotizing gastritis by Escherichia coli in a severely neutropenic patient
Carmen Martínez-Chamorro,
Elena Martínez*, Juan José Gil-Fernández,
Antonio Escudero, Agustín Acevedo°, José
Mª Fernández-Rañada
Hematology, Radiology* and Pathology° Departments;
Clínica Ruber, C/ Juan Bravo, 49, 28006 Madrid, Spain.
Correspondence: Carmen Martínez-Chamorro, C/ General
Oraá, 3-1º, 28006- Madrid, Spain. Phone: +34.1.
4111917. Fax: +34.1.4111853. E-Mail: m-chamorro@navegalia.com
Acute necrotizing gastritis is an extremely severe and uncommon condition in
the antibiotic era. We report a case of acute necrotizing gastritis caused by
Escherichia coli in a patient with severe acquired aplastic anemia,
successfully managed with conservative therapy. Biopsy and culture of gastric
mucosa established the diagnosis. A 59-year-old man with an unremarkable past
medical history was diagnosed of severe aplastic anemia. He was treated with
immunosuppressive therapy consisting of antithymocyte globulin (ATG) 20 mg/kg/day
for 8 days and cyclosporine A (CyA) 5 mg/Kg/day. Methylprednisolone 1 mg/kg/day
and omeprazole 40 mg/day were administered to prevent serum sickness and gastric
toxicity, respectively. He did not receive any antimicrobial prophylaxis other
than oral nystatin. On the 5th day of therapy, the patient developed severe
non-irradiated, non-colicky, epigastric pain, hiccups, nausea and vomiting.
Examination disclosed upper abdominal tenderness without signs of peritonitis.
Serum amylase value was normal. Abdominal radiography was unremarkable. Computed
tomography revealed marked thickening of the gastric walls with involvement
of adjacent fat tissue (Figure
1). ATG, CyA and corticoids were withdrawn,
and morphine was added to relieve abdominal pain. On the 7th day, the patient
showed intense vomiting yielding abundant fetid hematic material and his temperature
rose to 38.6°C. Upper gastrointestinal endoscopy showed an extremely narrowed
gastric lumen with diffuse involvement of the stomach walls and pyloric stenosis;
resembling an infiltrative process. Gastric biopsy samples were taken for pathological
examination and culture. The patient was treated with nasogastric tube drainage,
empirical antimicrobial therapy with meropenem and amikacin and total parenteral
nutrition. Gastric mucosa cultures yielded isolates of Escherichia coli
and pathologic examination of biopsy specimens revealed extensive necrosis and
a large amount of bacteria in gastric mucosa, but no neoplastic infiltration
(Figure 2). The patient's
clinical condition progressively improved and allowed satisfactory oral tolerance
three weeks later. Immunosuppressive therapy with CyA and G-CSF was reintroduced.
The patient was discharged with a partial response in granulocyte count and
transfusion-dependent platelet and red blood cell counts. Acute necrotizing
gastritis is a variant of phlegmonous gastritis1 and occurs secondary
to an over-whelming necrobiotic infection.2 Since 1945, fewer than
50 cases of phlegmonous gastritis have been described.3,4 In spite
of neutropenia leading to a significant propensity to infection, to our knowledge,
acute necrotizing gastritis associated with neutropenia has not been reported
in English literature. Besides, pre-operative diagnosis has been sparsely made.
The pathogenesis is unclear, although described predisposing factors are mucosal
injury, achlorhydria, immunocompromised states, upper respiratory and bucco-pharyngeal
infections.5 Most cases have been caused by hemolytic streptococci
(70%), but pneumococci, staphylococci, Proteus, Haemophilus influenzae,
Escherichia coli and Clostridia have been also reported.6
In contrast to other reported cases, we did not observe infiltration of neutrophils
or focal abscesses in the gastric wall, as inflammatory response to infection
is limited in neutropenia. No distant infective focus was identified and blood
cultures were negative. We hypothesized that omeprazole-induced hypochlorhydria,
which might have altered gastric bacterial flora, neutropenia and immunosuppressive
treatment, and gastric mucosal injury due to corticosteroids and thrombocytopenia
might have facilitated the development of acute necrotizing gastritis. We conclude
that acute necrotizing gastritis should be included in the differential diagnosis
of acute epigastralgia in immunocompromised patients. Early diagnosis by endoscopy
with biopsy and culture and prompt treatment with antibiotics and supportive
measures are important in managing this life-threatening infection, especially
in pancytopenic patients.
Key Words: necrotizing gastritis, Escherichia coli, neutropenia.
References
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- Strauss RJ, Friedman M, Platt N, Gassner W, Wise L. Gangrene of the stomach: a case of acute necrotizing gastritis. Am J Surg 1978; 135:253-7.
- Wakayama T, Watanabe H, Ishizaki Y, et al. A case of phlegmonous esophagitis associated with diffuse phlegmonous gastritis. Am J Gastroenterol 1994; 89:804-6.
- Merino MT, Falguera M, Panadés MJ, García M. Gastritis flemonosa en un paciente con úlcera gástrica crónica. Med Clin 1997; 109:50-1.
- Schultz MJ, van der Hulst RW, Tytgat GN. Acute phlegmonous gastritis. Gastrointest Endosc 1996; 44:80-3.
- Miller AI, Smith B, Rogers AI. Phlegmonous
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