neutropenia, types causes treatment

1. Neutropenia

3. Introduction
• Leukopenia refers to a decrease in the total WBC count (granulocytes,
monocytes, and lymphocytes).
• Granulocytopenia is a deficiency of granulocytes, which include
neutrophils, eosinophils, and basophils.
• A reduction in neutrophils is termed neutropenia
(The neutrophilic granulocytes (neutrophils), which play a key role in
phagocytizing pathogenic microbes, are closely monitored in clinical
practice as an indicator of a patient’s risk for infection.)

4. • The absolute neutrophil count (ANC) is determined by multiplying the
total WBC count by the percent of neutrophils.
• Neutropenia is defined as ANC less than 1000 cells/µL (1 × 10 9 /L).
Normally, neutrophils range from 2200 to 7700 cells/µL.
• Severe neutropenia is defined as an ANC less than 500 cells/µl

5. Causes
Autoimmune Disorders
Felty syndrome
Systemic lupus erythematosus
Drugs
Alkylating agents (busulfan)
Antiinflammatory drugs (indomethacin)
Antimetabolites (methotrexate, mercaptopurine, cytarabine)
Antimicrobial agents (ganciclovir, penicillin G, trimethoprim/sulfamethoxazole)
Antitumor antibiotics (daunorubicin, doxorubicin)
Cardiovascular drugs (captopril, procainamide)
Diuretics (hydrochlorothiazide)
 Miscellaneous (ticlopidine, penicillamine)

6. Continued..
Hematologic Disorders
 Aplastic anemia
Congenital (cyclic neutropenia)
Fanconi syndrome (a defect of proximal tubule leading to
malabsorption of various electrolytes and substances)
Idiopathic neutropenia
Leukemia
Myelodysplastic syndrome

7. • Infections
• Fulminant bacterial infection (e.g., typhoid fever, miliary tuberculosis)
• Parasitic
• Rickettsial
• Viral (e.g., hepatitis, influenza, HIV, measles)

8. Continued..
Others
• Bone marrow infiltration (e.g., carcinoma, tuberculosis, lymphoma)
• Hemodialysis
• Hypersplenism
• Nutritional deficiencies (cobalamin, folic acid)
• Severe sepsis
The most common cause of neutropenia: chemotherapy and
immunosuppressive therapy
A term we use to describe the lowest point of neutropenia (and other blood
cells) in a patient treated with chemotherapy is nadir

9. Clinical features
• The patient with neutropenia is predisposed to infection with
opportunistic pathogens and nonpathogenic organisms from the
normal body flora.
• The classic manifestations of inflammation—redness, heat, and
swelling—may not occur.
• WBCs are the major component of pus. Therefore, in the patient with
neutropenia, pus formation (e.g., as a visible skin lesion or as lung
infiltrates on a chest x-ray) is absent.
• Minor infections can lead rapidly to sepsis and death.

10. Continued..
• The mucous membranes of the throat and mouth, skin, perineal area,
and pulmonary system are common entry points for pathogenic
organisms in susceptible host
• Sore throat and dysphagia, ulcerative lesions of the pharyngeal and
buccal mucosa, diarrhea, rectal tenderness, vaginal itching or
discharge, shortness of breath, and nonproductive cough.
• Any report of minor pain or any other symptom by the patient may be
significant and should be reported to the HCP at once.
• These seemingly minor problems can progress to fever, chills, sepsis,
septic shock, and death if not recognized and treated early

11. Diagnostic evaluation
• The primary diagnostic tests for assessing neutropenia are the
peripheral WBC count and bone marrow aspiration and biopsy.
• A differential count can confirm the presence of neutropenia
(Absolute neutrophil count less than 1000/µL [1 × 10 9 /L]).
• If the differential WBC count reflects an absolute neutropenia of 500
to 1000/µL (0.5 to 1.0 × 10 9 /L), the patient is at moderate risk for a
bacterial infection.
• An absolute neutropenia of less than 500/µL (0.5 × 10 9 /L) places the
patient at severe risk.

12. Continued..
• A peripheral blood smear assesses for immature forms of WBCs (e.g.,
bands).
• The hematocrit level, reticulocyte count, and platelet count are done to
evaluate bone marrow function
• bone marrow aspiration and biopsy is done to
• examine cellularity and cell morphology.
• Other studies may be done to assess spleen and liver function.

13. • Cultures of sputum, throat, lesions, wounds, urine, and feces may
part of patient surveillance.
• Depending on the clinical situation, it may be necessary to do CT
scans, bronchoscopy with bronchial brushings, or lung biopsy to
diagnose the cause of pneumonic infiltrates

14. Management: components
• Determining the cause of the neutropenia
• Instituting antibiotic therapy promptly
• Identifying the offending organisms if an infection has developed,
• giving hematopoietic growth factors prophylactically after
chemotherapy,
• Implementing protective practices (e.g., strict hand washing, skin and
oral hygiene)

15. Antibiotic therapy
• Monitor the neutropenic patient for signs and symptoms of infection
(e.g., any fever 100.4°F [38°C] or greater) and early septic shock.
• Early identification of a potentially infective organism depends on
obtaining cultures from various sites.
• Serial blood cultures (at least 2) or 1 from a peripheral site and 1 from
a venous access device should be done promptly and antibiotics
started within 1 hour.

16. • Giving broad-spectrum antibiotics is usually by the IV route because
of the rapidly lethal effects of infection.
• Some oral antibiotics are highly effective and routinely used for
prophylaxis against infection in some neutropenic patients.
• The use of a third- or fourth-generation cephalosporin with broad
microorganism coverage (e.g., cefepime, ceftazidime) or a
carbapenem (e.g., imipenem/cilastatin [Primaxin]) will be started and
augmented

17. Antifungal
• The longer the neutropenia, the greater the risk is for a fungal
infection.
• Antifungal therapy is started whenever a culture is positive, or in
patients who do not become afebrile with broad-spectrum antibiotic
coverage.

18. • Myeloid growth factors can be used to prevent neutropenia or to
reduce its severity and duration.
• Once neutropenia has occurred, these agents are generally not as
effective
• Hand washing is the single most important preventive measure to
minimize the risk for infection in the neutropenic patient.
• Strict hand washing by staff and visitors using an antiseptic hand
wash before and after contact is the major method to prevent
transmission of harmful pathogens.

19. • Separate immunocompromised patients from those who are infected
or have conditions that increase the probability of transmitting
infections (e.g., poor hygiene caused by lack of understanding or
cognitive dysfunction).
• If the patient is hospitalized, a private room should be used.
• High-efficiency particulate air (HEPA) filtration is an air-handling
method with a high-flow filtering system that can reduce or eliminate
the number of aerosolized pathogens in the environment used for
hematopoietic stem cell transplant patients

20. High efficiency particulate filter

21. • WASH YOUR HANDS frequently and make sure those around you
wash their hands frequently, especially if they help with your care.
You may also use an antibacterial hand gel. 2. Notify your nurse or
HCP if you have any of the following: Fever ≥100.4°F (38°C) ∗ Chills or
feeling hot Redness, swelling, discharge, or new pain on or in your
body Changes in urination or bowel movements Cough, sore throat,
mouth sores, or blisters 3. If you are at home, take your temperature
as directed and follow instructions on what to do if you have a fever.
4. Avoid crowds and people with colds, flu, or infections. If you are in
a public area, wear a mask and use hand sanitizing gel frequently. 5.
Avoid uncooked meats, seafood, or eggs and unwashed fruits and
vegetables. Ask your HCP about specific dietary guidelines for you

22. • Bathe or shower daily. Use a moisturizer to prevent skin from drying
and cracking. 7. Maintain some daily activity as instructed by your
health care team. This may include walking and moderate exercise
while avoiding crowds. 8. Brush your teeth with a soft toothbrush 4
times daily. You may floss once daily if it does not cause excessive
pain or bleeding. Avoid alcohol-based mouthwashes. 9. Do not
garden or clean up after pets. You may feed and pet your dog or cat if
you wash your hands well after handling.