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Case histories

image Two patients presented directly to the oncology centre with fever. Patient 1 was a 22-year-old man with no comorbidities who had recorded a temperature of 38.0°C at home 12 days after his first cycle of adjuvant chemotherapy for testicular cancer. He felt well and had no localizing symptoms. His vital signs were: temperature 38.0°C; pulse 80 beats/min; blood pressure 125/80 mmHg. A full blood count revealed: haemoglobin 101 g/l; white blood cell count 1 × 109/l; neutrophil count 0.4 × 109/l; platelet count 200 × 109/l.

Patient 2 was a 63-year-old man with chronic obstructive pulmonary disease (COPD). He was unwell and dehydrated, 7 days after his third cycle of palliative chemotherapy for bowel cancer. His vital signs were: temperature 38.8°C; pulse 124 beats/min; blood pressure 110/70 mmHg. A full blood count revealed: haemoglobin 92 g/l; white blood cell count 0.5 × 109/l; neutrophil count 0.08 × 109/l; platelet count 100 × 109/l.

A phone call was received from the local district general hospital requesting advice about an oncology patient who had presented with fever to the emergency department. The patient (patient 3) was a 52-year-old woman, with a peripherally inserted central catheter line in situ, presenting with a history of rigors, 9 days after her fourth cycle of adjuvant chemotherapy for breast cancer. She had been receiving primary prophylaxis with pegfilgrastim after each cycle, to reduce the risk of neutropenia. Her vital signs were: temperature 36.8°C; pulse 112 beats/min; systolic blood pressure 90 mmHg (diastolic blood pressure unrecordable); respiratory rate 24 breaths/min. A full blood count revealed: haemoglobin 89 g/l; white blood cell count 0.7 × 109/l; neutrophil count 0.1 × 109/l; platelet count 120 × 109/l.

What is febrile neutropenia?

Can the risk of febrile neutropenia be reduced?

How should febrile neutropenia be evaluated?

How should each of these patients be assessed and managed?

What is febrile neutropenia?

Febrile neutropenia is defined as a temperature ≥38°C and a neutrophil count <0.5 × 109/l in a patient undergoing anticancer treatment, most commonly cytotoxic chemotherapy.1 Radiotherapy and newer systemic anticancer treatments such as molecularly targeted agents and immunotherapy have a much lower propensity to cause neutropenia. Patients with haematological malignancies undergoing cytotoxic chemotherapy have a relatively higher rate of febrile neutropenia compared with patients treated for solid tumours such as lung cancer. After administration of most cytotoxic agents, the neutrophil count nadir typically occurs between days 10 and 14, but there is significant variation between different drugs and patients.

Febrile neutropenia is a significant cause of cancer-related mortality: between 2001 and 2010, the number of attributable deaths doubled, even after adjusting for the increasing number of cancers diagnosed during this period.1 The majority of febrile neutropenic deaths are in those aged 65–79 years. The explanation for the rising mortality is unclear ...

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