14: Febrile Neutropenia

PATIENT PRESENTATION

Chief Complaint

“I have a fever and chills.”

History of Present Illness

JP is a 34-year-old Caucasian male who is admitted to inpatient oncology service for induction chemotherapy for a recent diagnosis of acute myeloid leukemia (AML). His induction chemotherapy regimen consists of 7 + 3 induction chemotherapy with cytarabine and daunorubicin. He was placed on neutropenic precautions, started on appropriate antimicrobial prophylaxis, and a port was placed for chemotherapy administration. Ten days after the completion of his induction chemotherapy (day 17), he spiked a fever of 38.8°C (101.8°F) and complained of chills and nausea. Details of the hospital course by day are detailed below:

Past Medical History

Epilepsy, depression

Surgical History

Appendectomy (10 years ago)

Family History

Father had AML and passed away 8 years ago; mother has hypertension and epilepsy; no siblings

Social History

Married with twins (5 years old). Has never smoked and denies illicit drug use. Drinks alcohol socially. He was previously enlisted in the Navy and is currently a gym teacher at a local elementary school.

Allergies

Penicillin (reaction: rash)

Home Medications

Sertraline 1000 mg PO daily

Divalproex sodium delayed-release 1000 mg PO BID

Levetiracetam 1000 mg PO BID

Multivitamin PO daily

Inpatient Medications

Sertraline 1000 mg PO daily

Divalproex sodium delayed-release 1000 mg PO BID

Levetiracetam 1000 mg PO BID

Posaconazole delayed-release 300 mg PO BID ×1 day followed by 300 mg PO daily (day 1 start)

Valacyclovir 500 mg PO BID (day 1 start)

Levofloxacin 500 mg PO daily (day 1 start)

Review of Systems (day 17)

Positive for fever, chills, and nausea; denies vomiting, cough, diarrhea, or abdominal pain

Physical Examination (day 17)

Vital Signs

Temp 38.8°C, P 105 bpm, RR 16 breaths per minute, BP 112/78 mm Hg, pO₂ 98%, Ht 5′ 8″, Wt 74 kg

General

Male with fatigue and in mild to moderate distress

HEENT

PERRLA, EOMI, good ...