Oncologic Emergencies
Zaid Al-Harbash
Introduction
Incidence of childhood malignancy 1:100,000
Most common: leukemia, followed by solid tumors of the brain and spinal cord
Fever and Neutropenia
Infections remain the major cause of morbidity and mortality among cancer patients
Most common bacterial organisms found in febrile neutropenia: Staphylococcus, Streptococcus, Enterococcus, Corynebacterium, E. coli, Klebsiella, Pseudomonas
Neutropenia is defined as absolute neutrophil count (ANC) < 0.5 × 109/L, or 0.5-1 × 109/L and expected to fall
Absolute neutrophil count is the sum of all mature and band forms of polymorphonuclear cells
Risk of Infection
• | Bacteremia or sepsis | 12-32% |
• | Pneumonia | 3-13% |
• | Urinary tract infection | 1-5% |
• | No documented infection | 67% |
Clinical Assessment
Obtain thorough history and examine for sites of infection
Pay special attention to:
Mucosa and perioral areas, skin, and perianal areas for ulcerations or lesions
Central line for cellulitis
Abdomen for typhlitis or neutropenic colitis
Signs of inflammation may be minimal in neutropenia:
Abscess may manifest as pain without erythema or swelling
Pneumonia may manifest as tachypnea alone
Investigations
CBC and blood cultures should be taken peripherally and from the central line
Obtain peripheral cultures immediately on arrival in the emergency department
Urinalysis and culture: avoid catheterization in neutropenic patients
Chest X-ray in patients with respiratory symptoms
Treatment
Initiate antibiotic therapy immediately if febrile and neutropenic
Involves IV dual therapy with a β-lactam and aminoglycoside
Add vancomycin if suspect central line infection
If signs of perirectal involvement, consider anaerobic coverage
If signs of herpes simplex virus or varicella zoster virus infection, add acyclovir
Admit and monitor with hourly vital signs for first 4 hours and then q 4 h as indicated
Tumor Lysis Syndrome
Due to breakdown of cells of a rapidly growing tumor (e.g., Burkitt’s lymphoma, T-cell leukemia)
Can occur at onset of therapy
Intracellular contents are released leading to:
Hyperkalemia → cardiac arrhythmias
Hyperuricemia → uric acid nephropathy
Hypocalcemia → weakness, tetany, seizures, and arrhythmiasRelated posts:
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