Musab bin shuayl, MD

CASE PRESENTATION

HISTORY: A 37-year-old woman with non-Hodgkin’s lymphoma (diffuse large B-cell lymphoma)

presented to the emergency room (ER) complaining of

fever, nausea, vomiting, and diarrhea(non bloody) for 2 days . She reported having chemotherapy 5 days ago.

Past medical history :

The patient’s large cell lymphoma was initially diagnosed in 2010 after she developed a mass in the left side of her neck. Lymph node biopsy was positive for large cell lymphoma CD20+. Bone marrow biopsy was negative. She was treated with cyclophosphamide doxorubicin/vincristine/prednisolone (CHOP) for 6 cycles.

HISTORY: FAMILY HISTORY

Her father died of colon cancer at age 83. Her mother had a cardiovascular accident at age

68 ,but is alive and otherwise healthy. She has 2 sisters, aged 33 and 26 years, who are healthy and alive

SOCIAL HISTORY

She is teacher and has no children. She has a 10-year smoking history but quit 3 months ago .

ALLERGY HISTORY : -VE

SYSTMIC REVIEW : unremarkable

PHYSICAL EXAMINATION:the patient appeared fatigued and weak. She was experiencing chills, overall, looked ill

temperature of 101.8°F (38,8)

respiratory rate of 20 breaths/minute

heart rate of 122

blood pressure of 80/50 mm Hg.

LAB ASSESSMENTS

CBC with differential

BUN, SCr

Electrolytes

LFTs

Urinalysis

Blood & urine cultures was taken

WBC=2.2, Neutrophil = 0.42 (2-7.5), Hgb=99 Plt=345

BUN=3, SCr=87

Na=139, K=3.6, Cl=104, HCO3=28

Tbili=16, ALT=117, AST=76, Alp=84

Normal

HOSPITAL COURSE: The patient’s immediately started on Iv fluid(NS) and antibiotics (piperacillin and torbramycin).

Because of her unstable blood pressure and other signs of sepsis, she was quickly transferred to the intensive care unit (ICU) .

In the ICU she continued on IV fluid antibiotics and pressors were started to maintain the blood pressure. She was subsequently intubated as a result of volume overload from fluid

resuscitation. She was tapered off pressors 24 hours later and extubated 48 hours later .

cultures had no growth during her hospital stay. She was transferred to the oncology ward, finished her antibiotics and 12 days later was sent home.

Neutropenic Fever

NEUTROPENIC FEVER

Neutropenia is defined as an abnormally low level of neutrophils in the blood .

1 .Absolute Neutrophil Count (ANC) calculation :

ANC = (WBC count) x (neutrophil % + band %)

ANC<500 cells/microliter

ANC<1000 cells/microliter, falling, predicted nadir <500

Fever

>38.0°C (100.4°F) for more than 1 hour

-Neutropenic fever is a potentially fatal complication of anti-cancer treatment (Mortality

rates ranging between 15 and 20%. )

-Without timely treatment, studies showed a mortality rate of nearly 70%!!

PATIENTS AT RISK

Neutropenia is a common side effect of many types of chemotherapy.Anyone on antineoplastic medication needs to be closely followed for the development of neutropenia.

Patients undergoing treatment for hematologic malignancies are at higher risk for developing neutropenia.

Acute lymphoblastic leukemia: 93%

CHOP (Non-Hodgkin): 22%

Cisplatin/etoposide (SCLC): 38%

Fluorouracil (colon): 22%

Ozer H et al. JCO 2000; 18: 20 3558-3585.

PATHOGENESIS

Impaired skin barrier Directly from IV access, or from chemo side effects

Impaired immune system

Abnormal anatomy/occluded excretory mechanismsBiliary, bronchial, urinary from either tumor or post-surgical alterations in anatomy

COMMON PATHOGENS TO CONSIDER IN A NEUTROPENIC PATIENT

Gram positive organismsS. Aureus

S. Epidermidis

Streptococcus spp.Enterococcus

Corynebacterium

Gram negative organismsPseudomonas

Klebsiella

E. Coli

Keep these in mind when initiating treatment

IT COULD BE ANYTHING!

CONCLUSION

A. Patients who are neutropenic and febrile should be considered unstable and seen promptly .

B. Antibiotics should be administered immediately upon the patient's arrival

Offer beta lactam monotherapy cefepime or ceftazosin with piperacillin-tazobactam as initial empiric antibiotic therapy for suspected neutropenic fever

C- Prior to any antibiotic administration, cultures must be obtained .

CONCLUSION

D- COMPLETE PHYSICAL EXAM must be performed .

Carefully examine the skin, mouth, buccal mucosa, IV sites, external genitalia, and perirectal area

E. LABORATORY EXAM should include:

1 .Complete blood count with differential and platelets

2 .Aerobic and anaerobic cultures

3 .Electrolytes, BUN, Cr, Ca, Phos, Mg

4 .Liver function tests (AST, ALT, Bili)

5 .Urinalysis with microscopic exam (if symptomatic)

6 .Cultures of other sites if symptomatic

CONCLUSION

If the patient is:

a. Afebrile for at least 24 hours

b. The blood cultures are negative 36-48 hours after being obtained

c. There is no identification of a localized infection

d. ANC≥1000 .

If any of the above 4 criteria are NOT present, the patient should remain hospitalized and on antibiotics. Consider fungal or viral causes

•Neutropenic sepsis is a potentially fatal complication of anti-cancer treatment

•Aggressive use of inpatient intravenous antibiotic therapy has reduced morbidity and mortality 5

THANKS!

NEUTROPENIC