Patient A presented with an episode of neutropenic sepsis. As a junior you should be suspicious of someone being neutropenic if they have had recent chemotherapy (usually within the past 1-2 weeks). Reviewing patients previous blood results can be useful as depending on their diagnosis they may be chronically neutropenic.
The important learning point from this case is to initiate emergency treatment immediately, do not wait until bloods results are available. Patients who are neutropenic can become profoundly septic over a short period of time and therefore responding to the initial temperature is essential. In this case the patient had a hickman line, which is the possible source of infection. He spiked a temperature after the line had been accessed and had no other symptoms to suggest a source of infection. Once the patient started showing signs of septic shock, we should consider removing the line.
Increased susceptibility to infection is likely to occur when the neutrophil count falls to <1000/mm^3 with escalating risk at <500/mm^3
Initial management of neutropenic sepsis
- Full history and exam + initial abx dose within one hour of diagnosis of acute sepsis
- Administration of abx as per local protocol
- Blood culture – from line and peripheral
- FBC/CRP/U&Es/LFTS/coag/G&S/Blood gas/ECG/CXR
- Fluid balance
- Urine MSU, Sputum culture, Line swab if evidence of infection at exit site, consider viral throat swabs if symptomatic
- Consider GCSF – discuss with haem registrar
- EARLY review by HDU/ITU team
Patient A later received a blood transfusion during which he developed symptoms. These symptoms may have been attributable to his ongoing sepsis, however the possibility of a blood transfusion reaction must be consider and investigated.
Acute transfusion reactions reaction can present with a range of symptoms including:
- Fever – chills, rigors, myalgia, nausea, vomiting
- Cutaneous symptoms
- Respiratory symptoms – dyspnoea, stridor, wheeze, hypoxic
- Severe anxiety – feeling of impending doom
- Bleeding diathesis
This patient develops a temperature shortly after commencing a transfusion.
- Consider underlying infection causing temp
- Consider blood transfusion –
- if mild temp rise (1-2 degrees C) consider giving paracetamol/slow infusion/antihistamine.
- If moderate temp rise (>2 degrees C +/- systemic symptoms) – treat as reaction as below
Immediate management should include:
- Disconnecting the transfusion and giving set (retain this for further investigation)
- Maintain IV access with N.saline
- High flow O2
- If wheeze – salbutamol
- If suspicion of anaphylaxis (hypotension.wheeze/stridor)– adrenaline
- If suspicion of ABO incompatibility or bacterial contamination (severe hypotension without signs of anaphylaxis or fluid overload) – fluid resuscitation/inotropic support/check identity of transfusion and recipient/blood cultures+broad spectrum abx.
- If suspicion of TRALI or TACO – patent airway/ high flow O2/CXR
The patient should then be discussed with haematology/transfusion team for further investigation of possible transfusion reaction.
Spinal cord compression
Patient B had a diagnosis of IgG MGUS, which has progressed to myeloma.
Symptoms of spinal cord compression can include:
- Sensory loss
- Limb weakness
- Walking difficulty
- Sphincter disturbance
This is medical emergency and requires rapid recognition and treatment.
Upon clinical suspicion, Dexamthasone 40mg daily for 4 days should be commenced and urgent MRI organised. It is of importance to differentiate between soft tissue and bone related cord compression. The case should be discussed immediately with the neurosurgical/orthopaedic team if there is a need for surgical intervention in the case of spinal instability or structural compression. Soft tissue disease should be treated with radiotherapy, preferably commenced with 24 hours of presentation.
Obviously in this patient we would wish to repeat immunoglobulins, SFLC, FBC, calcium, U&ES +/- bone marrow biopsy to confirm the suspicion of myeloma.
Thanks for your contributions
- Guidelines on investigation and management of acute transfusion reactions. http://www.bcshguidelines.com/documents/ATR_final_version.pdf
- Guidelines on diagnosis and management of myeloma. http://www.bcshguidelines.com/documents/MYELOMA_Mngmt_GUIDELINE_REVISION_Sept_2010.pdf