Internal Medicine · Year 3 · from Internal Medicine
Case 2: Neutropenic Fever
Patient Presentation
A 62-year-old woman with acute myeloid leukemia presents 10 days after completing induction chemotherapy with fever and chills. She denies cough, dysuria, abdominal pain, or diarrhea. She has a tunneled central venous catheter (Hickman) in her right subclavian vein placed 3 weeks ago. The catheter site appears clean without erythema or discharge.
Vital Signs
- Blood Pressure: 95/60 mmHg
- Heart Rate: 112 bpm
- Respiratory Rate: 22/min
- Oxygen Saturation: 96% on room air
- Temperature: 39.1°C
Physical Examination
- General: Ill-appearing, mild rigors
- HEENT: Oral mucosa with mild mucositis, no thrush
- Cardiovascular: Tachycardic, regular rhythm, no murmurs
- Pulmonary: Clear to auscultation
- Abdomen: Soft, non-tender, no hepatosplenomegaly
- Skin: No rashes, no perirectal tenderness or fluctuance
- Central line site: No erythema, tenderness, or discharge
Initial Workup
- CBC: WBC 200/μL (ANC 50/μL), Hgb 8.1 g/dL, Platelets 22,000/μL
- BMP: Creatinine 1.1 mg/dL, normal electrolytes
- Lactate: 2.8 mmol/L
- Blood cultures: Drawn from central line and peripherally (pending)
- Chest X-ray: No infiltrates
- Urinalysis: No pyuria or bacteriuria
Clinical Image
Figure 2: Oral mucositis following chemotherapy, representing a common portal of entry for pathogens in neutropenic patients.
Image Source: Educational illustration for teaching purposes.
Questions
- What defines neutropenic fever?
- A) ANC <1000/μL with temperature >38.0°C once
- B) ANC <500/μL with temperature >38.3°C once or >38.0°C sustained for 1 hour
- C) ANC <1500/μL with temperature >39.0°C
- D) ANC <100/μL with any documented fever
- What is the most appropriate empiric antibiotic regimen?
- A) Vancomycin plus metronidazole
- B) Ceftriaxone plus azithromycin
- C) Cefepime or piperacillin-tazobactam monotherapy
- D) Ciprofloxacin plus amoxicillin-clavulanate
- When should vancomycin be added to the initial empiric regimen?
- A) All cases of neutropenic fever
- B) Hemodynamic instability, suspected catheter infection, skin/soft tissue infection, or known MRSA colonization
- C) Only if blood cultures are positive for gram-positive organisms
- D) After 48 hours if fever persists
- What is the MASCC score and how does it guide management?
- When should antifungal coverage be added to the regimen?
Answers
- B) ANC <500/μL with temperature >38.3°C once or >38.0°C sustained for 1 hour - This is the standard definition of neutropenic fever. Patients with ANC expected to decline to <500/μL should also be considered at risk.
- C) Cefepime or piperacillin-tazobactam monotherapy - Monotherapy with an anti-pseudomonal beta-lactam is the standard initial treatment for neutropenic fever. Both provide broad coverage including Pseudomonas aeruginosa.
- B) Hemodynamic instability, suspected catheter infection, skin/soft tissue infection, or known MRSA colonization - Vancomycin is not routinely indicated but should be added for specific indications. Empiric vancomycin does not improve outcomes in uncomplicated neutropenic fever.
- MASCC score (Multinational Association for Supportive Care in Cancer):
- Risk stratification tool for neutropenic fever
- Scores ≥21 indicate low risk (mortality <5%)
- Points assigned for: burden of illness, no hypotension, no COPD, solid tumor or no fungal infection, no dehydration, outpatient status, age <60
- Low-risk patients may be candidates for oral antibiotics or outpatient management
- Antifungal coverage indications:
- Persistent fever after 4-7 days of appropriate antibiotics
- Clinical deterioration despite antibiotics
- New pulmonary infiltrates during antibiotics
- Known colonization with Candida or Aspergillus
- Empiric coverage typically with echinocandin or voriconazole