# Necrotizing Enterocolitis in an Infant With a History of Twin-Twin Transfusion Syndrome: A Case Report

## TL;DR

This case report details an infant with a history of twin-twin transfusion syndrome who developed necrotizing enterocolitis, a severe intestinal condition requiring surgery.

## Contribution

The report highlights the rare but serious complication of NEC in infants with TTTS, emphasizing the need for early recognition and intervention.

## Key findings

- The infant presented with symptoms of NEC, including bloody diarrhea and emesis, and was diagnosed with pneumatosis intestinalis.
- The patient required surgical resection of the diseased intestine and was successfully discharged after recovery.
- The case underscores the increased risk of NEC in infants with TTTS due to prematurity and intestinal hypoperfusion.

## Abstract

This case report describes necrotizing enterocolitis (NEC) in an infant with a history of twin-twin transfusion syndrome (TTTS). TTTS is a volume imbalance where the anastomosis at the vascular equator between the two placentae shifts from the donor to the recipient twin. This causes a higher risk for NEC, a marked inflammation caused by bacterial infection into the intestinal wall, from prematurity and intestinal hypoperfusion. Complications include sepsis, bowel necrosis, perforation, peritonitis, and death. NEC is a leading cause of morbidity in preterm infants.

A 3-month-old female with a history of TTTS and prematurity presented with her mother to the pediatric emergency department (ED) for bloody diarrhea, emesis, lack of appetite, and lethargy for 4 days. The pediatrician changed the formula due to a possible milk allergy, however, she continued to have bloody diarrhea. Over the 2 days, the patient had nonbilious and non-bloody emesis and couldn’t tolerate oral intake.

In the ED, labs showed neutropenia and sepsis. She had a positive fecal occult blood test (FOBT) and an abdominal x-ray that revealed dilated loops of bowel and pneumatosis intestinalis. She was started on intravenous (IV) fluids for maintenance of hydration. She was started on broad-spectrum antibiotics including intravenous (IV) vancomycin and meropenem, and had her feedings temporarily stopped. The patient was transferred to the pediatric intensive care unit (PICU) at a tertiary care/children's hospital that evening where she had a laparotomy performed to resect the diseased intestine. She was discharged 10 days after the surgery for home recovery with clinical follow-up.