A 62-year-old woman arrives at the emergency department reporting fevers, chills, and prof… — USMLE Step 2 CK

A $62$ -year-old woman arrives at the emergency department reporting fevers, chills, and profound fatigue over the past $12$ hours. She is currently undergoing multi-agent chemotherapy for diffuse large B-cell lymphoma; her last infusion was $10$ days ago. Her temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), blood pressure is $112/72\text{ mm Hg}$ , pulse is $95\text{/min}$ , and respiratory rate is $16\text{/min}$ . Physical examination reveals a totally implanted central venous access device in her right chest with no surrounding erythema, induration, or tenderness. Lungs are clear to auscultation. There are no skin rashes or oral ulcers.

Laboratory results are as follows:

Laboratory test	Result
Hemoglobin	$8.8\text{ g/dL}$
Platelets	$95,000\text{/mm}^3$
Leukocytes	$600\text{/mm}^3$
Segmented neutrophils	$15\%$
Band forms	$5\%$
Creatinine	$1.1\text{ mg/dL}$
Total bilirubin	$0.9\text{ mg/dL}$

A chest radiograph shows no focal consolidation.

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

A
Obtain blood cultures and initiate oral ciprofloxacin and amoxicillin-clavulanate
B
Administer filgrastim and discharge with close outpatient follow-up
Obtain blood cultures and initiate intravenous cefepimeCevap
D
Initiate intravenous vancomycin and amphotericin B
E
Withhold antimicrobial therapy until blood culture results identify a specific organism

Cevap

The most appropriate next step is to obtain blood cultures and immediately initiate intravenous cefepime.

The correct answer involves obtaining blood cultures and immediately starting an intravenous antipseudomonal beta-lactam, such as cefepime. Febrile neutropenia is a medical emergency defined by an absolute neutrophil count (ANC) of less than

500\text{/mm}^3

and a single oral temperature of

\geq 38.3^\circ\text{C}

(

101.0^\circ\text{F}

) or

\geq 38.0^\circ\text{C}

(

100.4^\circ\text{F}

) sustained over

1

hour. This patient's ANC is

120\text{/mm}^3

(

600 \times 0.20

). Due to the high risk of rapid clinical deterioration from bacterial sepsis (particularly Pseudomonas aeruginosa), prompt initiation of empiric broad-spectrum intravenous antibiotics is mandated. Cefepime, meropenem, or piperacillin-tazobactam are the standard of care for high-risk patients.

Adım Adım Çözüm

Calculate the Absolute Neutrophil Count (ANC).

ANC is

120\text{/mm}^3

(Total Leukocytes

600 \times 0.20

[segmented + bands]).

To confirm the presence of profound neutropenia, which is defined as an ANC less than

500\text{/mm}^3

Identify the clinical syndrome based on the presentation.

The patient has febrile neutropenia.

The patient has a single oral temperature of

38.9^\circ\text{C}

concurrent with severe neutropenia.

Risk-stratify the patient to determine the appropriate treatment setting and route.

This is a high-risk presentation.

Patients with hematologic malignancies undergoing active multi-agent chemotherapy who develop profound neutropenia are automatically classified as high-risk and require inpatient intravenous management.

Select the appropriate empirical antimicrobial therapy.

Intravenous cefepime.

Guidelines mandate immediate empiric monotherapy with an antipseudomonal beta-lactam (e.g., cefepime, meropenem, or piperacillin-tazobactam). Additional coverage with vancomycin is not indicated because there is no hemodynamic instability, port infection, or severe mucositis.

Anahtar Kavram

High-risk febrile neutropenia is an oncologic emergency that requires immediate blood cultures followed by prompt initiation of an intravenous antipseudomonal beta-lactam.

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru