Common neutropenic sepsis exam questions for medical finals, OSCEs and MRCP PACES
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What is the definition of neutropenic sepsis (neutropenic fever)?
- Neutrophils < 1 x109 / L is the most widely used criterion (thought some guidelines recommend <0.5×109/L)
- AND any of
- Temperature > 38°C OR
- Signs or symptoms indicating infection OR
- Raised C-reactive protein (>80mg/L)
What can be done to prevent neutropenic sepsis (neutropenic fever)?
- Improve counts
- G-CSF can be used following chemotherapy regimens with a high risk of prolonged neutropenia
- Prophylaxis against infection
- Antibiotic prophylaxis with a fluoroquinolone reduces febrile episodes and mortality
- Antifungal prophylaxis with fluconazole 50mg PO once daily
- Antiviral prophylaxis with aciclovir 200mg PO three times daily
What are the causes of neutropenia?
- Benign ethnic neutropenia; cyclical neutropenia; Chediak-Higashi
- Failure of production leading to pancytopenia
- Myelosuppressive chemotherapy or irradiation is overwhelmingly the most common.
- Others include infiltration of bone marrow by cancer; vitamin B12 or folate deficiency; myelodysplastic syndrome; aplastic anaemia
- Increased consumption
- Idiosyncratic drug reactions (e.g. carbimazole; clozapine; co-trimoxazole; penicillin)
- Autoimmune disease e.g. SLE; autoimmune neutropenia (antibody-mediated neutrophil destruction)
- Paroxysmal noctural haemoglobinuria
- Haemophagocytic syndrome
How do you investigate neutropenic sepsis (neutropenic fever)?
- Blood cultures (peripheral and line), urine culture, stool if diarrhoea
- Other fluids (pus, sputum, pleural fluid, ascites, CSF, synovial fluid) as relevant for microbiology
- Relevant viral serology if clinical suspicion
- FBC, U+E, LFT, C-reactive protein or ESR, coagulation, calcium, lactate, glucose
- Blood film
- Group and screen
- CXR if indicated
- Further imaging as dictated by history and examination to identify a source
When should lines be removed in neutropenic sepsis (neutropenic fever)?
- Central venous lines should not be routinely removed.
- They should be removed in cases of bacteraemia due to aureus, P. aeruginosa or fungal infection.
What is the myeloid reconstitution syndrome?
- As the neutrophil count recovers, some patients develop worsening symptoms and signs of focal infection
What is typhilits?
- Typhilis (also known as necrotising enterocolitis) is inflammation of the bowel in the context of neutropenia that is not due to a particular pathogen.
- It should be managed as neutropenic sepsis initially, though if perforation occurs surgery is required. Other causes of colitis should be ruled out (norovirus, C. difficile, cytomegalovirus, ischaemia)