Hematology Oncology · Year 2 · from Hematology Oncology

Case 1: Febrile Neutropenia

Patient Presentation

Demographics: 52-year-old female

Chief Complaint: Fever and chills after chemotherapy

History of Present Illness: The patient received her third cycle of R-CHOP chemotherapy for diffuse large B-cell lymphoma 10 days ago. She developed fever (38.8C), chills, and mild cough this morning. She denies any specific localizing symptoms but feels generally unwell.

Past Medical History:

  • DLBCL diagnosed 6 weeks ago
  • No other significant medical history

Medications:

  • R-CHOP chemotherapy (last dose 10 days ago)
  • Ondansetron PRN
  • No prophylactic antibiotics

Physical Examination:

  • Temperature: 38.9C
  • Blood pressure: 98/62 mmHg
  • Heart rate: 108 bpm
  • General: Ill-appearing, mild rigors
  • HEENT: Oral mucosa intact, no thrush
  • Lungs: Clear to auscultation
  • Abdomen: Soft, non-tender
  • Skin: No rashes, no cellulitis, no perianal tenderness

Workup and Results

Laboratory Studies:

  • WBC: 800/mcL
  • ANC: 120/mcL (severely neutropenic)
  • Hemoglobin: 10.2 g/dL
  • Platelets: 92,000/mcL
  • Creatinine: 1.0 mg/dL
  • Lactate: 2.8 mmol/L

Blood Cultures: Pending (2 sets drawn)

Chest X-ray: No infiltrates

Urinalysis: Normal

Clinical Image

Diagram illustrating the approach to febrile neutropenia, emphasizing the critical importance of rapid broad-spectrum antibiotic administration within 60 minutes of presentation.

Diagnosis

Febrile Neutropenia - High Risk

Criteria met:

  • Fever: Temperature ≥38.3C single reading
  • Neutropenia: ANC <500/mcL (severely neutropenic at 120)
  • High-risk features: ANC <100, anticipated prolonged neutropenia

Discussion

This case illustrates febrile neutropenia management:

  • Definition: The lecture defines febrile neutropenia as ANC <500/mcL (or expected to decrease to <500) with temperature ≥38.3C single reading or ≥38.0C sustained over 1 hour.
  • Oncologic Emergency: The lecture emphasizes that febrile neutropenia is an oncologic emergency requiring immediate broad-spectrum IV antibiotics. Mortality increases with each hour of delay.
  • Absent Localizing Signs: The lecture explains that neutropenic patients cannot mount a normal inflammatory response, so classic infection signs may be absent. Pneumonia may show no infiltrate initially; cellulitis may lack erythema.
  • Anti-pseudomonal Coverage: The lecture specifies that empiric therapy must cover Pseudomonas aeruginosa, a common and dangerous pathogen in neutropenic patients.

Treatment Plan

  1. Immediate Broad-Spectrum IV Antibiotics (within 60 minutes):
  • Cefepime 2g IV every 8 hours
  • OR Piperacillin-tazobactam
  • OR Carbapenem if high-risk resistant organisms
  1. Additional Coverage Considerations:
  • Add vancomycin if: mucositis, skin/catheter infection, hemodynamic instability, known MRSA
  • Antifungal coverage if fever persists >4-7 days
  1. Supportive Care:
  • IV fluids for hypotension
  • G-CSF consideration (filgrastim) if high-risk/prolonged neutropenia expected
  1. Monitoring:
  • Daily CBC
  • Blood cultures if recurrent fever
  • Look for occult infection source
  1. Duration:
  • Continue until ANC >500 and afebrile for 48 hours
  • Minimum 7 days typically

Teaching Points

  1. Febrile neutropenia = ANC <500 + fever ≥38.3C (or ≥38.0C sustained)
  2. Immediate IV antibiotics within 60 minutes - oncologic emergency
  3. Must cover Pseudomonas (cefepime, pip-tazo, carbapenem)
  4. Neutropenic patients may lack inflammatory signs despite severe infection
  5. Add vancomycin for mucositis, skin infection, hemodynamic instability

All cases for this lecture as Markdown