FEBRILE NEUTROPENIA

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FEBRILE NEUTROPENIA
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J Age- 4 1/2 yrs
Diagnosis-Acute Lymphhoblastic leukaemia
(FAB L2) Date
of diagnosis 26 December2001
Symptoms-Recurrent fever
Bone pains 3 wks
Extreme lethargy

Investigations- Peripheral smear, bone
marrow confirmed diagnosis of acute
lymphoblastic leukaemia (FAB L2)
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• Risk factors- Male, high TLC and
  significant organomegaly
• No
  lymphadenopathy
• Management Chemotherapy with 4
• week,4 drug induction protocol.
  
• Marrow on D28 M1 (remission status)
• Next phase - I2- Radiation
• CNS prophylaxis
  
• Standard drugs.
  
• However,7 days into I2 phase of
  therapy he was brought with history of
  fever,lethargy
• and refusal to eat.He also had cough
  and
• looked toxic.

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• Examination Mucositis in the mouth and
• throat B/L coarse crepitations in the lungs.
• No hepatosplenomegaly.
• Investigations Blood counts, Peripheral blood
  smear, X-ray, CRP, blood and urine cultures
  

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• The smear and count reports were as follows-
• Hb 8gm
• Total WBC1300/cumm
• N 08
• L 78
• M 08
• E 06
• ANC104/cumm
• Platelets36,000/cumm
• CRP 96 u/ml

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The peripheral smear of this child is shown
below. What can you see in this slide?
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• The smear shows significant neutropenia.
• The large cell on the left is a band form and
  the one on the right is a myelocyte. Both cells
  show toxic granulations. This picture suggests a
  shift to the left indicative of sepsis.
• The next slide shows a normal peripheral smear.
• Can you make out the difference?

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• The child was subjected to radiological
  investigation and the X ray was as below

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• The X ray shows bilateral soft infiltrates
  suggestive of bronchopneumonia.
• As the recordings of temperature revealed
• continuous fever of more than 38 degrees C, the
  child was immediately started on empirical
  antibiotic therapy.
• What would your choice of antibiotics be in this
  situation?
• What are the standard dosages of these drugs?

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The blood culture, sample for which was collected
at admission, revealed a significant growth of
an organism after 48 hrs as seen on the blood
agar plate below
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• The organism grown was identified as Haemophilus
  influenzae which was found to be sensitive to a
  number of antibiotics. The plate below shows the
  sensitivity of the organism to ceftazidime.

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• The general condition of J remained stable
  for the next five days, but fever persisted.
  Blood cultures showed the following-
• A repeat count done on D5 after admission
  revealed Hb of 6gm
• TLC of 900/cumm
• N4 L88 M02 E06
• ANC 36/cumm
• Platelets 16 000/ cumm
• With the counts as above, platelet and RBC
  transfusions were considered.
• What is the role of these transfusions in a
  situation such as this?
• What is the threshold for platelet
  transfusion in a child whose general condition is
  stable and who is not bleeding?

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• However, clinical examination revealed no
  evidence of
• bleeding and the mucositis had not worsened.A
  repeat of the
• chest X ray did not reveal any further
  deterioration.
• Considering the clinical picture,what steps would
  one take now ?
• What is the role of packed cell RBC
  transfusion in a child with thrombocytopenia?
• Would you consider empirical antifungal
  therapy now? Why?
• What drug would you use?

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• Would you consider colony stimulating factors?
  How
• are they used?
• The boy was given a packed cell transfusion-
• What is the volume of blood to be transfused?
• and started on antifungal therapy with
  flucanazol.
• What is the dose of flucanazole? Amphotericin B?
• G-CSFwas considered but not started.
• Why?

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• Because G-CSF is useful when started early with
  neutropenia and has a limited role when
  neutropenia is fully established. Besides, it is
  expensive.
• The general condition of J gradually
• improved.He became afebrile after the 9th day of
  antibiotics
• and 4th day of antifungals. His mucositis
  improved and his
• cough reduced.
• His X- ray done on the 14th day after admission
  is shown next.

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• When can we consider discharging J?
• What is the ANC at which the child can be safely
• discharged?
• What prophylactic therapy would you advise Js
  mother to give him at home?
• What is the dosage and frequency of
  administration?
• What are the other preventive measures that
  should be followed?
• When would you like to review him again?

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