Hematology Oncology · Year 2 · from Hematology Oncology

Case 1: Febrile Neutropenia

Patient Presentation

Demographics: 54-year-old female

Chief Complaint: Fever and chills 10 days after chemotherapy

History of Present Illness: The patient has Stage IIIA breast cancer and received her second cycle of dose-dense AC (doxorubicin and cyclophosphamide) chemotherapy 10 days ago. She developed fever to 38.8C this morning with chills and rigors. She reports mild fatigue but denies cough, dysuria, abdominal pain, or diarrhea. She has no obvious source of infection. She did not receive G-CSF prophylaxis after this cycle.

Physical Examination:

  • Vital signs: BP 98/62, HR 112, RR 20, Temp 38.9C, SpO2 97% on room air
  • General: Ill-appearing, rigoring
  • HEENT: Oral mucosa with mild mucositis, no thrush
  • Lungs: Clear to auscultation bilaterally
  • Cardiac: Tachycardic, regular rhythm
  • Abdomen: Soft, non-tender, no organomegaly
  • Skin: Port-a-cath site without erythema or drainage
  • Perirectal: No tenderness, fluctuance, or erythema

Workup and Results

Complete Blood Count:

  • WBC: 800/uL (severely low)
  • Absolute Neutrophil Count (ANC): 120/uL (severe neutropenia)
  • Hemoglobin: 9.8 g/dL
  • Platelets: 95,000/uL

Chemistry:

  • Creatinine: 1.1 mg/dL
  • Lactate: 2.8 mmol/L (mildly elevated)

Infectious Workup:

  • Blood cultures x 2 (peripheral and port): Pending
  • Urinalysis: Normal
  • Chest X-ray: No infiltrates

MASCC Score:

  • Burden of illness (moderate symptoms): 3
  • No hypotension: 5
  • No COPD: 4
  • Solid tumor: 4
  • No dehydration: 3
  • Outpatient at fever onset: 3
  • Age <60: 2
  • Total: 24 (high risk if <21)

Clinical Image

Peripheral blood smear demonstrating severe neutropenia following myelosuppressive chemotherapy, with markedly reduced white blood cells and absence of neutrophils.

Diagnosis

Febrile Neutropenia - Medical Emergency

Criteria met:

  • ANC <500/uL (or <1,000/uL and expected to decline)
  • Single temperature ≥38.3C or sustained ≥38.0C for 1 hour
  • High-risk features: ANC <100/uL, anticipated prolonged neutropenia

Treatment Plan

  1. Immediate antibiotic therapy (within 1 hour of presentation):
  • Empiric anti-pseudomonal coverage: Cefepime 2g IV q8h
  • Alternatives: Piperacillin-tazobactam or meropenem
  1. Additional coverage considerations:
  • Vancomycin if: hemodynamic instability, suspected catheter infection, skin/soft tissue infection, or known MRSA colonization
  • Antifungal (voriconazole or caspofungin) if: fever persists >4-7 days despite antibiotics
  1. Supportive care:
  • IV fluid resuscitation
  • Monitor closely for sepsis and hemodynamic deterioration
  1. G-CSF:
  • Consider filgrastim if high-risk features or expected prolonged neutropenia
  • Will use G-CSF prophylaxis with subsequent chemotherapy cycles
  1. Disposition:
  • Inpatient admission given severe neutropenia and tachycardia
  • Daily monitoring until ANC recovery

Teaching Points

  1. Febrile neutropenia is a medical emergency requiring immediate empiric antibiotics
  2. The nadir of neutropenia typically occurs 7-14 days after myelosuppressive chemotherapy
  3. Patients may lack typical signs of infection (pus, infiltrates) due to absence of neutrophils
  4. The MASCC score helps identify low-risk patients who may be candidates for outpatient management
  5. Anti-pseudomonal coverage is essential given high mortality from gram-negative bacteremia
  6. G-CSF prophylaxis should be considered for regimens with >20% febrile neutropenia risk

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