Febrile Neutropenia in a Patient on Chemotherapy

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 55-year-old CM is admitted to the hospital with a chief complaint of fever for one day.

He has a history of unresectable lung cancer (NSCLC) and has completed 6 chemotherapy courses with carboplatin and doxorubicin. During the last chemotherapy session yesterday, he was found to be febrile and was admitted to the hospital. He reports no N/V/D/C, cough, CP or abdominal pain.

He gives a history of a 10-pound weight loss over the last month and difficulty chewing because of a tender lump on the left side of the face for 2-3 weeks.

PMH

Lung cancer, diagnosed 8 months ago in stage IIIb, previous episodes of hypercalcemia, last one 20 days ago, OA.

Medications

Prevacid (lansoprazole), trazodone, Benadryl (diphenhydramine), Percocet (oxycodone and acetaminophen), tramadol, senokot, doxepin, and Perphenazine.

SH

He does not drink, has a 25 pck-yrs smoking history, no illegal drug use.

What is the most likely diagnosis?

Pneumonia?
Sepsis due to neutropenia secondary to chemotherapy?
Tooth abscess?
Meningitis?
UTI?

Physical examination

VS 39.4-20-117-126/67.
Cachectic, in no acute distress.
HEENT: Left-sided mass, 2-3 cm in size, originating from the left part of the mandible (lower jaw), tender to palpation. Supple neck, no lymphadenopathy.
Chest: decreased AE in the right lung.
CVS: Clear S1S2.
Abdomen: WNL.
Extremities: no signs of infection.

Rectal exam? The rectal examination is relatively contraindicated in patients with febrile neutropenia due to risk to introduce infection and it was not done in this patient.


The temperature chart shows fever in febrile neutropenia (click to enlarge the image).

What laboratory work would you order?

CBC+DIFF
CMP
UA
Blood Cx x 2
CXR
EKG
Jaw X-ray vs. CT scan or MRI


CBCD and CMP in febrile neutropenia (click to enlarge the images).


X-ray showed bone metastases (left). Report of the X-Ray of the mandibula report: bone metastases suspected (right) (click to enlarge the images).


CT of the chest showed air fluid level due to lung cancer. Report of the CT (right).


CXR with an air fluid level due to lung cancer. CXR report (right).

What happened?

Cultures were negative. WBC was only 1,000 with ANC of 260/mm3.

Neutropenia definition is ANC of less than 500/mm3.

What antibiotics would you start after "pan-cultures"?

Zosyn (piperacillin and tazobactam and amikacin?
Vancomycin?

Monotherapy with either imipinem or Maxipime (cefepime) is usually enough, with the addition of vancomycin because this patient with frequent hospitalizations is at risk for MRSA infection.


List of medications (click to enlarge).

What happened next?

The patient's fever resolved and he had a bone scan investigation for his neck mass. A hospice care consult was called.

Final diagnosis

Febrile neutropenia due to chemotherapy.

What did we learn from this case?

In a febrile patient undergoing chemotherapy, always consider febrile neutropenia.

Treat febrile neutropenia promptly with:
-Isolation
-"Pancultures"
-Broad spectrum antibiotics (ABx)
-Neupogen (filgrastim, G-CSF)

References

Algorithm for initial management of febrile neutropenic patients. IDSA 2002.
2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer. IDSA Guidelines, 2002.
Filgrastim in Patients with Chemotherapy-induced Febrile Neutropenia: A Double-Blind, Placebo-Controlled Trial. Darryl W. Maher et al. Ann of Int Med, 1 October 1994 | Volume 121 Issue 7 | Pages 492-501.

Publsihed: 06/12/2004
Updated: 01/07/2009

4 comments:

  1. I would also start zometa for bone mets & to help with hypercalcemia; and five fractions of RT to the jaw for localized therapy relief...

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  2. Infectious Disease Society of America (IDSA) guidelines recommend against the empiric use of Vancomycin upon admission for febrile neutropenia. Its use is indicated if the patient has an indwelling intravenous catheter with local signs suggestive of infection (erythema, discharge, tenderness) or perhaps if the patient has mucositis from recent chemotherapy.

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  3. in this case, yes you should start Vanc as he has multiple admissions to the hospital.. risk of MRSA

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  4. I agre with addition of zoledronic acid with 1 of comments made earlier, need of vancomycin and choice of antibiotics is based on hospital based protocols and options of single agent meropenam/imipenam vs. cefepime vs. piptazo are reasonable in a patient with febrile neutropenia. Vancomycin choice is debatable in this patient.
    Shiyam Kumar, Oman

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