Oncologic emergencies – 4 – Febrile neutropenia

Oncologic Emergencies PART – 4
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we discussed Hyponatremia – seen in several cancers, most commonly lung cancer; nonspecific presenting symtposm; life threatening if below 120 especially if rapid; when to treat chronic hyponatremia; importance of avoiding intravenous hydration as most cases are due to SIADH – a condition which is actually treated by restricting fluids rather than giving fluids; limited benefit of increased salt intake if fluid restriction is not done.
Then we discussed Tumor Lysis Syndrome: seen mainly in acute leukemia, aggressive lymphoma; risk of very high potassium or very low calcium which are obviously fatal if not treated urgently; prevention is the key as treatment is frequently not possible in timely manner unless patient is already in hospital and under very close monitoring for expected TLS; how to prevent using agents to reduce uric acid, good hydration, avoiding high potassium foods; AVOIDING EVEN LOW DOSES OF STEROIDS in suspected acute leukemia or aggressive lymphoma.
Ans: Yes I would like to reemphasize the need to avoid empiric steroids in any patient, especially if any suspicion for hematologic malignancy. Even low doses of steroids can precipitate severe, fatal tumor lysis syndrome. Also, it can seriously hamper ability to make proper diagnosis, due to a partial change in overall picture, such as in bone marrow, blood picture, or even lymph node biopsy.
Que: What is the next important emergency?
Ans: Let us discuss Febrile Neutropenia. In the first part of this series, we mentioned following:
“Febrile neutropenia: someone who is under chemotherapy every 3 weeks in Ahmedabad, but lives 150 km away in your town, has been your patient for 25 years, and comes to you Saturday night for a fever of 101 F, but only mild weakness. This patient may die of sepsis in less than 24 hours, if his wbc count is low and does not receive intravenous antibiotics within few hours. He cannot be treated like a general fever – THIS IS AN EMERGENCY”
YES THIS IS TRULY A MAJOR EMERGENCY. During my training in USA, our patients were instructed to come straight to oncology ward for fever, and not wait in emergency room. Typically, in emergency room, there are many more dramatic emergencies with patients screaming in severe pain, trauma etc. A patient with total wbc count of only 500 and fever, on the other hand, may look fairly stable initially, with essentially normal blood pressure and pulse or only mild abnormalities. Such patients are frequently given less priority in a typical emergency room or at doctor’s place.
BUT THIS PATIENT MAY COLLAPASE IN NEXT FEW HOURS FROM BACTEREMIA with severe hypotension, without timely and proper antibiotic cover. And this is not a theoretical concern. It is well documented and every oncologist has experienced this first hand at least once in their career.
Hence if you have a patient on chemotherapy and has fever, do assume that he has low counts, and treat as an emergency. We give printed instructions to all chemotherapy patients, mentioning criteria for febrile neutropenia, when to report to doctor, with names and doses of few antibiotic options. Later allows treating doctor to make quick decision and start therapy.
First take blood culture (if available), CBC and other basic lab, and give first dose of antibiotic right away. Don’t wait for any blood reports to give antibiotic. Definition of neutropenia is ANC (absolute neutrophil count) below 1500.

• A temperature over 101 F once ; or if 100.4 F and same or higher after one hour. In practice, however we use even lower cutoff, especially for patients with blood cancers.
• Blood culture bottle: if not available, don’t wait. We see this frequently in or outside hospitals, where people are waiting for culture bottle to arrive for few hours. Antibiotic has to be administered within 30 minutes of patient arrival.
• Drug of choice: preferred drug is higher generation cephalosporin such as Cefepime tazobactum, cefepime, ceftazidime, or piperacillin tazobactum. But if not available, better to give almost any intravenous antibiotic rather than waiting for right antibiotic. Even a dose of aminoglycoside like Amikacin or ceftriaxone etc would still be far better than waiting for few hours.
• High risk patients: blood cancer (leukemia, lymphoma, myeloma mainly), first cycle of chemotherapy even in solid tumor, elderly, multiple comorbidities.
• Oral options: if you are at a place where intravenous antibiotics are not available, or sometimes getting venous access is too difficult (patients with poor vein, more commonly women, children, obese patients) – give one dose of oral Amoxicillin clavulanate 625 mg and one dose of Levofloxacin 750 mg – and then send patient to nearby facility for intravenous dose. Also contact treating oncologist in the meantime – he may guide you re how much urgency is there – as he may know patient’s latest blood count etc details.
  January 15th 2020. Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com