Baseline characteristics
There were 25 males and 23 females in the study cohort. Most of them
belonged to age group 3-5 years (42%) followed by children aged 10-18
years (25%). Acute myeloid leukemia (AML) was the most common
underlying diagnosis among the children with NEC (31%), followed by
acute lymphoblastic leukemia (ALL) (29%), non-Hodgkin lymphoma (NHL)
(13%) and relapsed ALL (8%). However, the proportion of children
developing NEC was the highest in NHL (40%), followed by AML (32%) and
relapsed ALL (20%). Fifty percent of children received anthracyclines
and etoposide prior to development of NEC. Cytarabine and
methotrexate-based chemotherapy was administered prior to 45% and 20%
of episodes respectively. Steroids were administered in 35% of the
cases. Alkylating agents were administered in 29% of the cases. In 54%
episodes, children developed neutropenic enterocolitis following the
first cycle of chemotherapy.
Fever was the most common symptom in the study population, present in
98% of the cases. It was followed by pain abdomen (88%) and diarrhoea
(83%). Vomiting, abdominal distension and blood in stools were less
common, present in 27%, 19% and 15% respectively. Coexisting oral
mucositis was observed in 50% of the cases, most of them had grade
II-III mucositis (Table 1). Hypoproteinaemia was prominent with median
of 5.4 g/dL, 28 of 46 (60%) had serum protein less than 5.5 g/dL.
Hypoalbuminemia was also evident, with median serum albumin of 2.9 g/dL,
78% of the children had serum albumin less than 3.5 g/dL.
On etiological evaluation, 17% of the cases showed blood culture
positivity. The most common isolate, Klebsiella pneumoniae , was
isolated in 6 cases. Staphylococcus aureus andStenotrophomonas maltophila were isolated in one patient each.
Serum procalcitonin, a biomarker associated with bacterial sepsis, was
elevated in 36 of 43 children (84%) (Cut-off 0.5 ng/mL). Blood fungal
culture and urine for fungus were negative. However, serum galactomannan
was elevated in 34% of children, which may reflect concomitant invasive
aspergillosis elsewhere. Blood for CMV PCR was negative in all patients.
Stool routine examination showed presence of Giardia and Entamoeba in 3
patients each. However, modified acid-fast staining did not show any
atypical organisms like Cryptosporidium in any of the cases.
CECT abdomen was done in 42 of 48 cases. Bowel wall thickening was
present in 36 children. Isolated small bowel involvement was seen in 2
children, isolated large bowel involvement was observed in 21 subjects,
involvement of both large bowel and small bowel was seen in 13 of 36
patients. Of those with colonic involvement, 16 children had involvement
of entire large intestine and 13 children had involvement of right sided
colon only. Isolated left colonic involvement was seen in 5 children.
Maximum bowel wall thickening ranged from 3.5 mm to 18 mm, with median
wall thickening of 6.5 mm. Seven children had thickening of 10 mm or
more. Bowel involvement was localised in 36 % and diffuse in 64%.
Abnormal bowel wall enhancement and mural stratification were observed
in 67% and 61% respectively. Abnormal fat stranding and upstream bowel
wall dilatation adjacent to involved segment were seen in 8% and 17%
respectively. 26% of children had associated free fluid. One child had
evidence of pneumatosis intestinalis, none had evidence of
pneumoperitoneum (Table 2).
Faecal calprotectin was significantly elevated in children with NEC as
compared to children without NEC and healthy controls with median values
of 87 µg/g, 52.5 µg/g and 42 µg/g respectively (p value
<0.001) (Table 3).