Benign Cisplatin-Induced Pneumatosis Coli

CASE REPORT Pneumatosis intestinalis is rare (prevalence ≈0.03%) and usually raises alarm for bowel ischemia.1 A 50-year-old woman treated with high-dose cisplatin and radiotherapy for supraglottic carcinoma, underwent a feeding gastrostomy for dysphagia; weeks later, she reported leakage at the tube site. A computed tomography scan of abdomen unexpectedly showed air within the cecal and ascending colon wall (Figure 1), which was not present 1 month before presentation (Figure 2). She had no signs of peritonitis on physical examination, acidemia, or portal venous gas. Laboratory tests are included (Table 1). The G tube was replaced. Patient was closely followed by surgery, but she remained asymptomatic, not needing any intervention. Cisplatin-induced mucosal injury, altered motility, bacterial overgrowth, and immunosuppression were felt to be contributory factors for radiologic finding of pneumatosis coli.2 We compare our case to the few reported cases of cisplatin-induced pneumatosis coli (Table 2).Figure 1.: Computed tomography scan of abdomen showing air within the cecal and ascending colon wall.Figure 2.: Computed tomography scan of abdomen 1 month prior showing normal colon/cecum. Table 1. - Laboratory tests comparing the patient's initial presentation laboratory values with those from the 1-mo presentation Laboratory test 1-mo before presentation At presentation Reference range Hemoglobin/hematocrit 10.9 gm/dL/31% 12.1 gm/dL/35% 12–16 gm/dL/37%–47% White blood cell count 1.6 K/CUMM 7.8 K/CUMM 3.4–9.4 K/CUMM Platelet count 164 K/CUMM 216 K/CUMM 140–410 K/CUMM PT/INR 14.5 s/1.1 13.4 s/1.0 11.4–14.34 s/0.9–1.1 BUN 17 mg/dL 15 mg/dL 7–25 mg/dL Sodium 137 mmol/L 138 mmol/L 136–145 mmol/L Potassium 3.8 mmol/dL 4.4 mmol/dL 3.5–5.1 mmol/L Chloride 94 mmol/dL 99 mmol/dL 98–107 mmol/L Bicarbonate 31 mmol/dL 29 mmol/dL 21–31 mmol/L Creatinine 0.9 mg/dL 0.6 mg/dL 0.6–1.3 mg/dL Glucose 145 mg/dL 109 mg/dL 70–105 mg/dL Albumin 3.7 gm/dL 4.3 gm/dL 3.5–5.7 gm/dL Total protein 6.7 gm/dL 7.8 gm/dL 6.0–8.3 gm/dL Serum lactate 1.0 mmol/L 0.9 mmol/L 0.5–2.0 mmol/L AST 11 IU/L 23 IU/L 13–39 IU/L ALT 8 IU/L 13 IU/L 7–52 IU/L ALP 73 IU/L 125 IU/L 34–104 IU/L Bilirubin (total) 0.5 mg/dL 0.4 mg/dL 0.3–1.0 mg/dL Procalcitonin 0.89 ng/mL 0.08 ng/dL ≤0.49 ng/dL ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; INR, international normalized ratio; PT, prothrombin time. Table 2. - Summary of reported cases of cisplatin induced pneumatosis intestinalis Case# Age Sex Cancer Treatment Case presentation CT findings/location of pneumatosis intestinalis Proposed mechanism Management/response 1 70 Male Stage II esophageal cancer Cisplatin and 5-fluorouracil (CF) On day 14 after chemotherapy: severe abdominal pain with lower abdomen tenderness Low grade fever, tachycardia. Elevated C-reactive protein level (3.7 mg/dL) and renal dysfunction. PI in entire colon and a small air bubble in the mesentery Gastrointestinal toxicity from cisplatin and 5-fluorouracil (CF) Treated conservatively; cessation of enteral nutrition, meropenem, selective decontamination of the digestive tract, and oxygenation. Symptoms improved 1 day later. CT on day 7 showed that the gas within the wall had disappeared. Second course of CF was cancelled.3 2 69 Male Advanced esophageal cancer Cisplatin and irinotecan and external beam radiation 5 wk after starting chemotherapy and radiation acute abdominal pain, nausea, and nonbloody diarrhea.Afebrile and stable vital signs, generalized abdominal tenderness, no peritoneal signs, neutropenic; white blood cell count of 470 c/cumm, arterial pH: 7.32 and a pCO2 of 43. Pneumatosis and thickening of the right colon, presence of portal venous air Gastrointestinal toxicity from irinotecan and cisplatin. Initially a high index of suspicion for ischemia and bowel necrosis, surgical exploration was done. Intraoperative findings included a normal colon and small bowel no palpable portal venous air, normal mesentery of the small bowel with palpable pulses. Treated supportively and his symptoms improved postoperatively.4 3 65 Female Squamous cell carcinoma of the left tonsil (pT2pN1M0) Surgery, adjuvant radiotherapy and chemotherapy (cisplatin) After the second cycle of cisplatin, the patient presented with dysphagia, dyspnea, cervical subcutaneous emphysema, unremarkable abdominal examination and laboratory tests. Cervical and thoracic subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, retropneumoperitoneum, and pneumatosis coli Cisplatin Conservative treatment with corticosteroids, antibiotics, and parenteral nutrition leads to progressive reduction of emphysema and radiological resolution of pneumatosis5 Our case 50 Female T3 N1 squamous cell carcinoma of the supraglottic larynx High-dose cisplatin and radiotherapy Incidental finding 1 month after completion of 3 cycles of chemotherapy, Normal vital signs, unremarkable physical examination and laboratory tests Colonic pneumatosis in the cecum and ascending colon Cisplatin Conservative: observation CF, cisplatin and 5-fluorouracil; CT, computed tomography. DISCLOSURES Author contributions: G. Arman contributed to the conception and design of the work, data analysis and interpretation, drafting and critical revision of the manuscript, and final approval of the version to be published. LA Alya contributed to the design of the work, data interpretation, drafting of the manuscript, and final approval of the version to be published. HN Arshad, senior author, contributed to the conception of the work, data interpretation, and critical revision of the manuscript for important intellectual content, and provided final approval of the version to be published, and is the article guarantor. All authors meet the ICMJE authorship criteria and agree to be accountable for all aspects of the work. Financial disclosure: None to report. Previous presentation: This case was presented as a poster at the local Southern Illinois ACP meeting. Informed consent was obtained for this case report.