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Case History

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Image not available. A 48-year-old man with a recent diagnosis of non-seminomatous germ cell tumour, currently working full time as a company director and otherwise fit and well, is now undergoing chemotherapy. He presents 10 days after his second cycle of chemotherapy, with a three-day history of fatigue, feeling generally unwell, with pyrexia and a cough. He is sent for assessment.

What is the likely diagnosis?

What are the important components of initial management?

How can deteriorating patients be identified?

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Background

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What is the likely diagnosis? Is this patient high risk?

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Image not available. Sepsis is the likely diagnosis. It is a recognized and potentially fatal complication of anticancer treatment, particularly chemotherapy. Neutropenic sepsis (NS) is the second most common reason for hospital admission among children and young people with cancer, with approximately 4000 episodes occurring annually in the UK. Systemic therapies to treat cancer have a risk of reducing the bone marrow's ability to respond to infection by reducing its ability to produce neutrophils and alter the immune response.

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Neutropenic sepsis is a medical emergency requiring immediate attention. These patients are very high risk as they can rapidly deteriorate and develop multiorgan failure and die. Patients receiving chemotherapy and radiotherapy should be warned about signs and symptoms of sepsis, which can occur during chemotherapy or up to six weeks after. Treatment and care should take into account patients' needs and preferences. Patients should be given verbal and written information on how and when to contact 24-hour specialist oncology advice, and how and when to seek emergency care (which may be at a site different from that where they receive their oncology treatment).

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Time is of the essence in the management of these patients, and evidence suggests that outcomes worsen with delays in resuscitation and increased time to appropriate antibiotic treatment.

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The mortality from sepsis if it is allowed to develop into severe sepsis is significant, and efforts have focused on early identification and treatment in an effort to limit progression.1 Once identified, the goal of sepsis treatment is to eliminate the underlying infection by removal of infected tissue or implants alongside the use of antibiotics. The remainder of care is supportive, aimed at allowing the body to overcome the septic response and recover. As yet there is no established therapy which is used to treat sepsis - response to therapy is highly variable and a high mortality persists.

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Screening tools have been introduced to identify patients at high risk of sepsis to ensure appropriate early treatment and management.2 An example of this can be found in Figure 5.1. Each oncology department should have its own protocols for dealing with suspected NS.

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Figure 5.1

Sepsis screening tool. SIRS, systemic inflammatory response syndrome.

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