Neutropenia
From Anvita Health Wiki
Contents |
More Specific Terms
Introduction
- Neutropenia is defined as < 2000 neutrophils + bands/ uL in the peripheral blood. It is classified:
- severe: < 500/ uL
- moderate: 500-1000/ mL
- mild: 1000-2000
Etiology
- increased destruction/ peripheral margination
- drugs (see pharmaceutical agents implicated in neutropenia)
- autoimmune disorders
- decreased production
- drugs (neutropenia may be associated with pancytopenia) (see pharmaceutical agents implicated in neutropenia)
- hematologic diseases
-
- metastatic solid tumors
- myelodysplasia
- myelofibrosis
- congenital hypoplastic neutropenia ( Kostmann's syndrome)
- cyclic neutropenia
- chronic idiopathic neutropenia
- subpopulations of suppressor T-cells that suppress granulopoiesis have been described
- more common in African-Americans
- peripheral pooling (transient neutropenia)
- acute bacterial endotoxemia
- hemodialysis
- cardiopulmonary bypass
Pathology
- when neutrophil count falls below 1000/ uL, there is a progressively increased susceptibility to bacterial & fungal infections
- infections are uncommon in patients with neutrophil counts > 500/ uL
- most serious infections associated with neutropenia occur in patients with neutrophil counts < 100/ uL
- infections:
- common pathogens in neutropenic patient
-
-
- Pseudomonas aeruginosa & other Pseudomonas spp
- Escherichia coli
- Klebsiella
- Enterobacter
- Serratia
- Acinetobacter
- Citrobacter
-
- most likely source of bacteremia in neutropenic patient without indwelling catheter is endogenous flora of the mouth or gastrointestinal ( GI) tract
- other sites of infection are skin & lung
Clinical-manifestations
- symptoms are usually associated with infection
- FEVER in a neutropenic patient is a MEDICAL EMERGENCY
- odynophagia
- painful defecation
- respiratory distress
- inflammation
- lethargy
- lymphadenopathy
- oral thrush
- skin lesions: abscesses
- tachycardia
- postural hypotension
- digital rectal exams are contraindicated in neutropenic patients
Laboratory
-
- white blood cell differential
- increased MCV suggests Vitamin B12 or folate deficiency
- left-shift, toxic granulation, Dohle bodies suggests response to infection or marrow in recovery phase
- absence of immature forms suggests toxic insult
- gold standard
- marrow infiltration ( myelophthisis)
- paucity of myeloid precursors in toxic insult
- myeloid hyperplasia in peripheral destruction & margination
- chromosome studies
- body fluid cultures in febrile patients
- blood cultures are essential in patients with neutropenia & fever
- culture sputum, urine & other fluids as indicated
Management
- treat underlying etiology
- eliminate potential offending pharmacologic agents if feasible
- granulocyte colony-stimulating factor ( G-CSF or Neupogen)
- granulocyte- macrophage colony stimulating factor ( GM-CSF or sargramostim [Leukine, Prokine])
- consult hematologist
- febrile neutropenia is a medical emergency
- hospitalization, unless
- no significant comorbidities ( pneumonia, hypotension)
- neutropenia expected to resolve within 7 days
- culturing of body fluids
- pathogens
- gram negative aerobic bacteria
- penicillin-resistant viridans Streptococci: ARDS
- fungi in patients with neutropenia > 7-10 days
- empiric intravenous ( IV) antibiotics
- first line agents
- vancomycin should be added within 48 h
- if patient fails to respond to initial therapy
- if gram positive cocci are cultured from blood
- metronidazole or clindamycin should be added for:
- perirectal abscess
- odontogenic infection
- severe, acute abdominal pain suggesting typhlitis
- empiric therapy for fungal infections in patients who fail antibacterial therapy after 3-7 days
- amphotericin B is drug of choice
- antibiotic therapy should be continued at least until the neutrophil count rises above 500/ uL
- low bacteria diet in patients with prolonged neutropenia
- avoidance of fresh fruits & vegetables
- may not improve outcomes [7]
- patients should avoid individuals with known communicable diseases
- prophylaxis against aerobic gram negative bacilli in patients expected to be neutropenic for more than 1 week
- fluoroquinolones reduced mortality ( RR 0.52) [6,7]
- Bactrim
- air filtration for bone marrow transplant patients
More General Terms
Additional Terms
- amphotericin B (Fungisone, Ambisone, Amphotec, Fungilin, LAMB, AmBisome)
- cefepime (Maxipime)
- ceftazidime (Fortaz, Tazidime, Tazicef)
- clindamycin (Cleocin, Cindesse, ClindaMax)
- filgrastim [G-CSF] (Neupogen, Lenograstim, Granulokine)
- fluoroquinolone
- granulocyte transfusion
- imipenem cilastatin (Primaxin)
- metronidazole (Flagyl, MetroGel)
- pharmaceutical agents implicated in neutropenia
- sargramostim [GM-CSF] (Leukine, Prokine, Leucomax)
- trimethoprim/sulfamethoxazole or cotrimoxazole (Bactrim, Septra, Cotrim, Sulfatrim, Sulfoxatrim, Trisulfam, Uroplus)
- vancomycin (Vancocin)
References
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 587-89
- Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
- Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 332
- Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 540
- Journal Watch 23(14):111-112, 2003 Paul M et al, BMJ 326:1111, 2003 [1]
- Journal Watch 25(17):136, 2005 Gafter-Gvili A, Fraser A, Paul M, Leibovici L. Meta-analysis: antibiotic prophylaxis reduces mortality in neutropenic patients. Ann Intern Med. 2005 Jun 21;142(12 Pt 1):979-95. PMID: [2]
- Gardner A et al, Randomised comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. J Clin Oncol 2008, 26:5684 PMID: [3]
- other articles
- PMID: [4] PMID: [5] PMID: [6] - National Guideline Clearinghouse Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. ngc-guideline: [7]
