Don’t be fooled. The patient with no immune system deserves significant respect and requires our vigilance.
Be thorough.Where is the source? Look at the mucous membranes and consider necrotizing fasciitis (i.e., look in the perineum)!
Be aggressive! If the child looks sick, throw all of the antibiotics at them. If the child looks well, monotherapy is recommended.
High Risk vs Low Risk… don’t decide alone. Your physical exam and lab results will help determine whether a patient is high risk or low risk, but that determination should be made concurrently with the patient’s oncologist.
Leukostasis occurs with WBC count greater than 50,000 with symptoms (usually 100,000), predominantly pulmonary and neurologic symptoms.80% of patients will have fever, so treat for infection concurrently. Chemotherapy is the only treatment that decreases mortality, but if not available, leukopheresis is the next step.
Neutropenic fever is defined as a single oral temperature greater than 38.3 oC or temperature >38.0 oC for one hour, with absolute neutrophil count (ANC) of < 1500 cells/microL, with severe defined as an ANC less than 500 cells/microL or an expected drop to < 500 over 48 hours. 30% of fevers are due to infection, with gram positives accounting for 60% of infections. Broad coverage targeting gram positives and pseudomonas is needed.
Venous Thromboembolism (VTE) (DVT, Pulmonary Embolism (PE))is common in cancer, with 15% of patients with malignancy experiencing DVT/PE. Khorana score is validated for VTE risk stratification in this patient population. CT PE and DVT US are the best tests. Anticoagulation with heparin has the best literature support for treatment.