Acute presentatons due to SACT/radiotherapy

Question 1

Neutropenic sepsis:

• Definition
• Risk factors (8)
• Causes (4)
• Symptoms (7)
• Signs (5)
• What to ask in history
• What to examine
• Investigations
• Management
• Prevention
• Extra facts - non chemo causes

Answer 1

Neutropenic sepsis:

• Definition: patients undergoing SACT with a temp >38C and neutrophils <0.5x109 per litre most common in patients receiving cytotoxic chemo
• Risk factors: neutropenia >7 days, aggressive cancer, central lines, mucosal disruption, inpatient, haematological malig, elderly, cormorb COPD/DM/renal or hepatic impairment
• Causes: staph aures, epidermidis, enterococcus, strep
• Symptoms: rigors, cough, sore throat, diarrhea, dysuria, skin lesions, mucositis
• Signs: fever, hr>90, hypotension (if <90 systolic URGENT), RR>20, drowsy/confused
• What to ask in history: type/timing chemo regimen/other meds, symptoms, recent infections/abx, any intravasc devices, cormorbs
• What to examine: temp, bp, HR, oxy sats, rr, peripheral perfusion, altered mental state, search for source of infection (chest exam, check central lines, any skin lesions, mouth and throat)
• Investigations: urgent bloods (fbc, u+es, lfts, crp, glucose, lactate), blood cultures (central + peripheral) (although often neg), MRSA screen, MSSU/CSU if symptoms, sputum, stool culture if diarrhea, wound swabs, CXR if chest signs
• Management: empirical IV abx within 1 hour (usually piperacillin-tazobactam)!! Don’t wait for fbc, fluid resus, oxy, catheter, if v septic can give granulocyte colony stimulating factor. Daily measure fever/bloods
• Prevention: all patients given 24 hour alert card, education, abx prophylaxis
• Extra facts
  Non chemo causes: hydroxychloroquine for RA, methotrexate for RA, sulfasalazine for RA

Question 2

Tumour lysis syndrome:

• Definition
• Pathophysiology
• Risk factors
• Symptoms
• Investigations
• Management

Answer 2

Tumour lysis syndrome

• Definition: metabolic emergency which presents as severe electrolyte abnormalities
• Pathophysiology: when starting treatment massive tumour cell lysis causes release of large amounts of K, phosphate, uric acid into systemic circ. This causes hyperuricaemia, hyperkal, hyperphosphataemia, hypocalcaemia and AKI from uric acid or ca phosphate cystals in renal tubules
  Haematological malig highest risk, most common in high grade lymphomas/leukaemias, less common in solid tumours
• Risk factors: high volume/bulky disease, LDH high pre treatment, high circ WCC, preexisting renal dysfunction, hyperuricaemia pre treatment, hypovolaemia, diuretic use pre treatment, urinary tract obstruction
• Symptoms: 3-7 days post chemo, N+V, diarrhea, anorexia, lethargy, fluid overload, haematuria/oligouria/anuric, arrhythmias (peaked T), muscle cramps, seizures
• Investigations: bloods (u+es deranged with K/pi high/ ca low, ldh inc), ecg
• Management: vigorous hydration, monitor electrolytes/ fluid balance, allopurinol (less hyperuricaemia), rasburicase (degrates uric acid to allantoin), dialysis

Question 3

Radiation mucositis:

• Definition
• Risk factors
• Symptoms
• Complications
• Management

Answer 3

Radiation mucositis:

• Definition: when cancer treatments (radio + chemo) break down rapidly dividing epithelial cells lining the GI tract causing ulceration/infection. If due to radiation due to the necrotic and inflammatory effect of radiation energy 1-3 weeks after starting radiation. Oral cavity most common place
• Risk factors: chemo/radio, poor oral hygeine, smoking, alcohol, poor fluids, women, younger
• Symptoms: red/swollen gums/mouth, blood, ulcers, difficulty swallowing/talking, feeling of dryness/pain when eating, pus, thicker saliva, bad breath
  If in gut: diarrhoea, ulcers bottom, bleeding, constipation, stomach cramps
• Complications: nutrition, increased risk infection/sepsis, disrupts treatment
• Management: cold/soft foods, avoid spicy/acidic/alc, ice cubes, good oral care, magic mouthwash, topical pain relievers (lidocaine), corticosteroids, photobiomodulation therapy (low level laser given during radiot course to prevent or treat)

Question 4

Thrombocytopenia:

• Definition
• Symptoms
• Investigations
• Management

Answer 4

Thrombocytopenia:

• Definition: low platelet count <150x109/l which inc risk bleeding, normally due to chemo as damage to bone marrow. Severe if <50, mod if 50-100, mild if >100
• Symptoms: mucosal bleeding, nosebleeds, haematemesis, red/black stools, red urine, heavy vaginal bleeding, bruises (<30), headaches, painful joints, severe bleeding after trauma
• Investigations: blood film, bloods (fbc, reticulocytes, prothrombin, U+es, lfts, coag screen), uss spleen
• Management: adjust chemo like longer wait during cycles, platelet transfusion if v low. Avoid contact sports, don’t blow nose with high force, stay away from nsaids

Question 5

Immunotherapy related colitis:

• Definition
• Symptoms
• Investigations
• Management

Answer 5

Immunotherapy related colitis:

• Definition: inflammation colon as heightened immune system also attacks healthy cells in colon
• Symptoms: diarrhoea, blood, mucus, abdominal cramps, fever, bloated
• Management: if mild loperamide and BRAT bland diet, if mod steroids, infliximab