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Case Histories

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Image not available. Two patients present directly to the oncology centre with fever. The salient features are as follows:

Patient 1: A 22-year-old man with no comorbidities has recorded a temperature of 38.0OC at home 12 days after his first cycle of adjuvant chemotherapy for testicular cancer. He feels well and has no localizing symptoms.

Vital signs for patient 1 read: temperature 38.0OC, pulse 80 bpm, blood pressure 125/80 mmHg. A full blood count reveals: Hb 10.1g/dl; WBC 1 ×109/l; neutrophils 0.4 × 109/l; platelets 200 × 109/l.

Patient 2: A 63-year-old man is known to have chronic obstructive pulmonary disease (COPD). He is unwell and dehydrated seven days after his third cycle of palliative chemotherapy for bowel cancer. Vital signs: temperature 38.8OC, pulse 124bpm, blood pressure 110/70 mmHg. Full blood count reveals: Hb 9.2g/dl; WBC 0.5 × 109/l; neutrophils 0.08×109/l; platelets 100×109/l.

Subsequently, you receive a call from the local district general hospital (DGH) regarding an oncology patient who has presented with fever to the emergency department (ED), and you are asked to advise. A summary of the verbal report is as follows:

Patient 3: A 52-year-old woman, with a peripherally inserted central catheter (PICC) line in situ has presented with a history of rigors nine days after her fourth cycle of adjuvant chemotherapy for breast cancer. She has been receiving primary prophylaxis with pegfilgrastim after each cycle, to reduce the risk of neutropenia. Vital signs: temperature 36.8OC, pulse 112bpm, blood pressure 90/unrecordablemmHg. A full blood count reveals: Hb 8.9g/dl; WBC 0.7×109/l; neutrophils 0.1 × 109; platelets 120 × 109/l.

What is febrile neutropenia?

How do you evaluate febrile neutropenia?

How would you assess and manage each of these patients?

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Background

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What is febrile neutropenia?

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Image not available. Febrile neutropenia is defined as a temperature of greater than 38oC, with a neutrophil count <0.5 × 109/l in a patient undergoing anticancer treatment, most commonly cytotoxic chemotherapy.1 Newer, biological systemic anticancer treatments and radiotherapy have a much lower propensity to cause neutropenia. Haematological malignancies have a relatively high rate of febrile neutropenia. Febrile neutropenia is a significant cause of cancer-related mortality, with the number of attributable deaths doubling between 2001 and 2010, even after adjusting for the increasing number of cancers diagnosed during this time period.1 The majority of febrile neutropenic deaths are in those aged 65-79 years. The explanation for the rising mortality is unclear, but may be related to the increasing use of chemotherapy, greater dose intensity, the treatment of patients who would previously have been considered too high risk for chemotherapy, and the increase in antibiotic resistance. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report into patient deaths within 30 days of receiving systemic anti cancer therapy also found evidence of ...

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