A 62-year-old woman comes to the emergency department due to a 1-day history of fever, chi… — USMLE Step 2 CK

A 62-year-old woman comes to the emergency department due to a 1-day history of fever, chills, and a productive cough. She was diagnosed with diffuse large B-cell lymphoma 3 weeks ago and completed her first cycle of R-CHOP chemotherapy 10 days ago. A central venous port was placed 4 days ago. Temperature is $38.8^\circ\text{C}$ ( $101.8^\circ\text{F}$ ), pulse is 112/min, respirations are 22/min, and blood pressure is 92/58 mm Hg. Pulse oximetry on room air shows 94%. Physical examination reveals right lower lobe crackles and a normal-appearing central port site with no surrounding erythema or induration.

Laboratory results are as follows:
Hemoglobin: 9.2 g/dL
Leukocyte count: $600/\text{mm}^3$
Neutrophils: 15%
Lymphocytes: 80%
Platelet count: $75,000/\text{mm}^3$
Serum creatinine: 1.1 mg/dL

Which of the following is the most appropriate next step in management?

Obtain blood and sputum cultures, then administer intravenous cefepimeCevap
B
Obtain blood and sputum cultures, then administer oral amoxicillin-clavulanate
C
Administer intravenous furosemide and obtain a transthoracic echocardiogram
D
Administer acetaminophen and observe for spontaneous resolution of postoperative fever
E
Withhold antibiotic therapy until culture and sensitivity results are finalized

Cevap

Obtain blood and sputum cultures, then administer intravenous cefepime

The correct answer is to obtain blood and sputum cultures, then administer an intravenous antipseudomonal beta-lactam such as cefepime. This patient has febrile neutropenia, defined as a single oral temperature of

\geq 38.3^\circ\text{C}

(

101.0^\circ\text{F}

) and an absolute neutrophil count (ANC)

< 500/\text{mm}^3

. Her ANC is calculated as

600 \times 0.15 = 90/\text{mm}^3

. Because her immune system is severely compromised, she is at extremely high risk for overwhelming sepsis, particularly from gram-negative organisms like Pseudomonas aeruginosa. The standard of care is to draw cultures (including from the central port and peripherally) and immediately initiate empiric broad-spectrum intravenous antibiotics.

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Calculate the Absolute Neutrophil Count (ANC).

ANC = Total Leukocytes × % Neutrophils =

600/\text{mm}^3 \times 0.15 = 90/\text{mm}^3

Determining the ANC is essential to assess the severity of immunosuppression after chemotherapy.

Identify the primary clinical syndrome.

The patient has a fever (

38.8^\circ\text{C}

) and an ANC <

500/\text{mm}^3

, meeting the criteria for febrile neutropenia.

Fever in the setting of severe neutropenia is an oncologic emergency with a high risk of rapid progression to septic shock.

Determine the appropriate intervention.

Immediate initiation of empiric broad-spectrum antibiotics with antipseudomonal activity (e.g., cefepime, piperacillin-tazobactam) after obtaining cultures.

Patients lack the white blood cells needed to fight off bacterial pathogens, necessitating aggressive and immediate antimicrobial support.

Anahtar Kavram

Management of Febrile Neutropenia

Soru

Cevap

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Anahtar Kavram

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