Lecture 36: Febrile neutropeania

Question 1

What might be observed on a bone marrow biopsy in a patient with acute myeloid leukeamia?

Answer 1

• High saturation of trephine
• Mainly blast cells
• Abnormal marrow architecture

Question 2

What does chemotherapy do in acute myeloid leukemia? whats the effect on the cell populations?

Answer 2

Obliterates leakeamic population of cells, leaving an empty bone marrow population

Cells:

• RBC; 120 day lifespan therefore no chance of anaemia yet
• Neutrophils and other granulocytes have 6hr or few day lifespan therefore this patient will become immunocompromised
• Platelets; Have short lifespan ~7 days and will need transfusion to be able to clot. At risk of bleeds

Question 3

What is febrile neutropeania in our treated acute myeloid leukeamia patient?

Answer 3

Febrile neutropeania

- Depleted neutrophils therefore very prone for infections

Question 4

Describe what might be observed upon history and examination in a patient with febrile neutropeania:

Answer 4

• Nothing to suggest site of infection, no cough, SOB, pain, urinary frequency, dysuria or skin infections etc

Just a temperature

Question 5

Write 5 notes on febrile neutropeania:

Answer 5

1. Common in severely neutropeanic patients
2. High rate of bacteraemia (30%)
3. Infections arise from endogenous gut and skin flora
4. Very high mortality in patients with gram negative bacteraemia
5. Improved outcome with emperic antibiotic treatment (started at presentation)

Question 6

When is risk of infection greatest in neutropeanic patietnts?

Answer 6

Prolonged, severe neutropeanic patients have highest risk of infection

Question 7

What are the sources of infection for neutropeanic patients?

Answer 7

• Constipation can cause damage to membranes
• Tooth brush damage
• Central lines

Question 8

What are the predominant causes of infection in neutropenic patients?

Answer 8

Staphylococci, streptococci, aerobic gram negative bacilli

Pseudomonas aeruginosa most common cause of infection

Question 9

Whats the initial treatment of a patient with febrile neutropenia?

Answer 9

Tazocin (Active against almost all aerobic bacteria) (Beta lactamase inhibitor)

plus

Gentamicin; Active against almost all aerobic gram negative bacilli (Aminoglycoside; inhibits protein synthesis; bacteriacidal)

Question 10

Whats the clinical course of febrile neutropeania?

Answer 10

• Gentamicin + tazocin commenced
• > Blood culture done, if coagulase negative staphylococcus identified; Vancomycin used.
• Recovery of neutrophil count observed from day 18 onwards with resolution of fever
• Proceed with tazocin only
• Bone marrow aspirate day 29 to confirm remission of AML

Question 11

Whats been done to improve outcomes of neutropenic patients?

Answer 11

• Antibiotic prophylaxis good

- Heamopoetic growth factors been used to reduce impact of neutropenia (if criteria met)