Chapter 143: Infections in Immunocompromised Patients: Making a Rash Decision Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Construct a prudent empiric antibiotic regimen for a febrile neutropenic patient.

• Determine appropriate situations to use vancomycin in empiric antimicrobial regimens for the treatment of febrile neutropenic episodes.

• Describe situations in which antibiotic monotherapy versus combination therapy would be warranted in the empiric treatment of febrile neutropenia.

PATIENT PRESENTATION

Chief Complaint

“I have a fever and chills.”

HPI

Scarlet Hives is a 60-year-old woman with a history of IgG kappa multiple myeloma who is undergoing an autologous hematopoietic cell transplant. Her stem cells were collected by peripheral blood collection, which were mobilized with cyclophosphamide and filgrastim. During collection she developed a vesicular rash involving her left lower abdominal quadrant, which was documented by PCR analysis to be herpes zoster. This was treated with valacyclovir. Her preparative regimen for transplant was high-dose melphalan, followed by stem cell rescue with her peripheral blood stem cells. Eight days after stem cell infusion, she spiked a fever of 38.6°C (101.5°F). She now also complains of chills and nausea.

PMH

• IgG kappa multiple myeloma

• GERD

• HTN

• Hyperlipidemia

• CAD

• Peripheral neuropathy

• Type 2 DM

• Chronic back pain

Surgical History

Hysterectomy—17 years ago

FH

Mother died of CAD at early age; father died at age 67 from lung cancer; has one sister and one brother, both living and well.

SH

High school cafeteria manager of 22 years, now retired. She is married and lives with her husband. She has three children. Denies smoking or ethanol use.

Home Meds

• Esomeprazole 40 mg PO once daily

• Atorvastatin 80 mg PO once daily

• Fentanyl patch 75 mcg Q 48 H

• Neurontin 800 mg PO TID

• Lisinopril 5 mg PO once daily

• Metoprolol 75 mg PO BID

• Multivitamin PO once daily

• Oxycodone IR 15 mg Q 6 H PRN pain

• Pioglitazone 15 mg PO once daily

• Promethazine 25 mg PO Q 6 H PRN nausea

• Valacyclovir 500 mg PO once daily, after previously completing 1,000 mg TID × 7 days for treatment course

• Fluconazole 400 mg PO once daily

• Levofloxacin 500 mg PO once daily

• Filgrastim 480 mcg subcutaneously daily

All

Ceftazidime—bad rash

ROS

(+) Fever/chills, (+) nausea; denies vomiting, cough, diarrhea

Physical Examination

Gen

Patient is a 60-year-old Caucasian woman who appears alert and oriented

VS

BP 115/83 mm Hg, ...