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Clinical Index of Stable Febrile Neutropenia

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261. Lymphoma, Follicular (Overview)

and varies across racial groups. See the image below. Follicular lymphoma, low-power view. Note the nodular pattern reminiscent of germinal centers. Photograph courtesy of Aamir Ehsan, MD. Signs and symptoms Follicular lymphoma is a type of non-Hodgkin lymphoma that most commonly presents as a painless, slowly progressive adenopathy. Systemic symptoms, such as fever, drenching night sweats, or weight loss in excess of 10% of ideal body weight, or asthenia, are infrequent at presentation but can (...) . A complete blood cell count (CBC) with differential should be obtained, including examination of the peripheral blood smear if the differential is abnormal. A chemistry panel and lactate dehydrogenase (LDH) level should be obtained. A computed tomography (CT) scan of the chest, abdomen, and pelvis can determine whether abdominal or pelvic adenopathy is present. Positron emission tomography (PET) scanning may also be useful in certain clinical settings, such as localized disease or when transformed

2014 eMedicine.com

262. Lymphoma, Mantle Cell (Overview)

virus type 1, human herpesvirus 6), environmental factors (pesticides, hair dyes), and primary and secondary immunodeficiency. Nonrandom chromosomal and molecular rearrangements play a major role in the pathogenesis of many lymphomas. The association of t(11;14)(q13;q32) with MCL suggests a causative role. Previous Next: Clinical Presentation History Findings on the history include the following: Stage IV disease in 70% of patients B symptoms, which include fever, night sweats, and weight loss (...) ibrutinib 560 mg daily plus palbociclib 100 mg days 1-21 of each 28-day cycle. The dose-limiting toxicity was grade 3 rash. The most common grade 3-4 toxicities included neutropenia (41%), thrombocytopenia (30%), hypertension (15%), febrile neutropenia (15%), and lung infection (11%). The overall and complete response rates were 67% and 37%, respectively, and with a median follow-up of 25.6 months, the 2-year progression-free survival was 59.4% and the 2-year response duration was 69.8%. A phase II

2014 eMedicine.com

263. Granulocytopenia (Overview)

with solid tumors who have undergone mild- to moderate-intensity chemotherapy, who appear to be clinically stable, and who are in close proximity to an appropriate medical facility that can provide 24-hour access, the Clinical Index of Stable Febrile Neutropenia (CISNE) may be used as an additional tool to determine the risk of major complications. [ ] Splenectomy In individuals with neutropenia and Felty syndrome who have recurrent, life-threatening bacterial infections, splenectomy is the treatment (...) for antibacterial prophylaxis is an oral fluoroquinolone, while that for antifungal prophylaxis is an oral triazole or parenteral echinocandin. [ ] A companion ASCO/IDSA guideline contains recommendations on outpatient management of fever and neutropenia in patients with cancer. The guideline recommends using clinical judgment and the Multinational Association for Supportive Care in Cancer (MASCC) scoring system or Talcott's rules to identify patients who may be candidates for outpatient management. In patients

2014 eMedicine.com

264. Hematopoietic Stem Cell Transplantation (Overview)

, and, in the most severe cases, surgery. may be helpful in viral infection with BK virus. [ ] Prolonged and severe pancytopenia Severe (< 500/µL but often < 100/µL), prolonged (up to 4 wk) neutropenia is common after transplantation and invariably requires the use of empiric broad-spectrum antimicrobials until recovery of the neutrophils. Empiric antifungal therapy with , , or other agents is often administered if unexplained fever persists despite the use of broad-spectrum antibacterials. Antiviral therapy (...) Aplastic anemia Pure red-cell aplasia Paroxysmal nocturnal hemoglobinuria Fanconi anemia Thalassemia major Sickle cell anemia Severe combined immunodeficiency (SCID) Wiskott-Aldrich syndrome Hemophagocytic lymphohistiocytosis Inborn errors of metabolism Epidermolysis bullosa Severe congenital neutropenia Shwachman-Diamond syndrome Diamond-Blackfan anemia Leukocyte adhesion deficiency HSCT-related morbidity and mortality Complications associated with HSCT include both early and late effects. Early-onset

2014 eMedicine.com

265. Toxicity, Cocaine (Overview)

Management The general objectives of pharmacotherapeutic intervention in cocaine toxicity are to reduce the CNS and cardiovascular effects of the drug. These are accomplished by using benzodiazepines initially and then controlling clinically significant tachycardia and hypertension while simultaneously attempting to limit deleterious drug interactions. Hyperthermia and rhabdomyolysis If psychostimulant-intoxicated patients do not die as a result of cardiac or cerebrovascular complications (...) . Hyperthermia, which may also be caused by downregulation of dopamine receptors, increases the incidence of fatal excited delirium. Death from excited delirium is more common in the summer months than at other times (55% vs 33% for other accidental cocaine toxicity deaths); therefore, high ambient temperature and humidity may play roles in the development of hyperthermia. An independent risk factor for fatal excited delirium is a body mass index (weight in kilograms/height in square meters) in the upper 3

2014 eMedicine.com

266. Hematopoietic Stem Cell Transplantation (Follow-up)

, and, in the most severe cases, surgery. may be helpful in viral infection with BK virus. [ ] Prolonged and severe pancytopenia Severe (< 500/µL but often < 100/µL), prolonged (up to 4 wk) neutropenia is common after transplantation and invariably requires the use of empiric broad-spectrum antimicrobials until recovery of the neutrophils. Empiric antifungal therapy with , , or other agents is often administered if unexplained fever persists despite the use of broad-spectrum antibacterials. Antiviral therapy (...) Aplastic anemia Pure red-cell aplasia Paroxysmal nocturnal hemoglobinuria Fanconi anemia Thalassemia major Sickle cell anemia Severe combined immunodeficiency (SCID) Wiskott-Aldrich syndrome Hemophagocytic lymphohistiocytosis Inborn errors of metabolism Epidermolysis bullosa Severe congenital neutropenia Shwachman-Diamond syndrome Diamond-Blackfan anemia Leukocyte adhesion deficiency HSCT-related morbidity and mortality Complications associated with HSCT include both early and late effects. Early-onset

2014 eMedicine.com

267. Agranulocytosis (Overview)

with solid tumors who have undergone mild- to moderate-intensity chemotherapy, who appear to be clinically stable, and who are in close proximity to an appropriate medical facility that can provide 24-hour access, the Clinical Index of Stable Febrile Neutropenia (CISNE) may be used as an additional tool to determine the risk of major complications. [ ] Splenectomy In individuals with neutropenia and Felty syndrome who have recurrent, life-threatening bacterial infections, splenectomy is the treatment (...) for antibacterial prophylaxis is an oral fluoroquinolone, while that for antifungal prophylaxis is an oral triazole or parenteral echinocandin. [ ] A companion ASCO/IDSA guideline contains recommendations on outpatient management of fever and neutropenia in patients with cancer. The guideline recommends using clinical judgment and the Multinational Association for Supportive Care in Cancer (MASCC) scoring system or Talcott's rules to identify patients who may be candidates for outpatient management. In patients

2014 eMedicine.com

268. Pneumonia, Bacterial (Follow-up)

for Healthcare Research and Quality. Pneumonia severity index calculator. Available at . Accessed: January 13, 2011. Sligl WI, Majumdar SR, Marrie TJ. Triaging severe pneumonia: what is the "score" on prediction rules?. Crit Care Med . 2009 Dec. 37(12):3166-8. . Phua J, See KC, Chan YH, Widjaja LS, Aung NW, Ngerng WJ, et al. Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia. Thorax . 2009 Jul. 64(7):598-603. . Bloos F, Marshall JC, Dellinger RP, et al (...) =aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzAwMTU3LXRyZWF0bWVudA== processing > Bacterial Pneumonia Treatment & Management Updated: Mar 19, 2019 Author: Justina Gamache, MD; Chief Editor: Guy W Soo Hoo, MD, MPH Share Email Print Feedback Close Sections Sections Bacterial Pneumonia Treatment Approach Considerations Almost all major decisions regarding management of pneumonia address the initial assessment of severity. See Risk Stratification under Clinical Presentation. Perhaps the most important initial determination is that of the need for hospitalization

2014 eMedicine.com

269. Lymphoma, Mantle Cell (Follow-up)

virus type 1, human herpesvirus 6), environmental factors (pesticides, hair dyes), and primary and secondary immunodeficiency. Nonrandom chromosomal and molecular rearrangements play a major role in the pathogenesis of many lymphomas. The association of t(11;14)(q13;q32) with MCL suggests a causative role. Previous Next: Clinical Presentation History Findings on the history include the following: Stage IV disease in 70% of patients B symptoms, which include fever, night sweats, and weight loss (...) ibrutinib 560 mg daily plus palbociclib 100 mg days 1-21 of each 28-day cycle. The dose-limiting toxicity was grade 3 rash. The most common grade 3-4 toxicities included neutropenia (41%), thrombocytopenia (30%), hypertension (15%), febrile neutropenia (15%), and lung infection (11%). The overall and complete response rates were 67% and 37%, respectively, and with a median follow-up of 25.6 months, the 2-year progression-free survival was 59.4% and the 2-year response duration was 69.8%. A phase II

2014 eMedicine.com

270. Mesothelioma (Follow-up)

was 50%. The most common nonhematologic toxicities included fatigue (20%), constipation (10%), vomiting (10%), and dehydration 10%. Hematologic toxicities included neutropenia (60%) and febrile neutropenia (10%). [ ] Single-agent pemetrexed Single-agent pemetrexed therapy showed a response rate of 10.5%, a median time to progressive disease of 6 months, and a median survival time of 14 months in chemo-naive patients. Of the pretreated patients, the response rate was 12.1% and median time (...) as possible is important to prevent postoperative complications. Pulmonary physiotherapy is very helpful because of the extensive lung resection in patients with malignant pleural mesothelioma. Follow-up Regular follow-up visits with an internist, pulmonary specialist, medical oncologist, and radiation oncologist are recommended. Next: Chemotherapy Currently, cisplatin as a single drug has been used as the standard drug for phase III clinical trials. None of the standard treatment options has improved

2014 eMedicine.com

271. Lymphoma, Follicular (Follow-up)

and varies across racial groups. See the image below. Follicular lymphoma, low-power view. Note the nodular pattern reminiscent of germinal centers. Photograph courtesy of Aamir Ehsan, MD. Signs and symptoms Follicular lymphoma is a type of non-Hodgkin lymphoma that most commonly presents as a painless, slowly progressive adenopathy. Systemic symptoms, such as fever, drenching night sweats, or weight loss in excess of 10% of ideal body weight, or asthenia, are infrequent at presentation but can (...) . A complete blood cell count (CBC) with differential should be obtained, including examination of the peripheral blood smear if the differential is abnormal. A chemistry panel and lactate dehydrogenase (LDH) level should be obtained. A computed tomography (CT) scan of the chest, abdomen, and pelvis can determine whether abdominal or pelvic adenopathy is present. Positron emission tomography (PET) scanning may also be useful in certain clinical settings, such as localized disease or when transformed

2014 eMedicine.com

272. Lymphoma, Mediastinal (Follow-up)

in fingertips and toes. Motor neuropathy is unusual. Myelosuppression (bone marrow suppression) and moderate pancytopenia occur after every treatment cycle. Blood counts typically reach their nadir approximately 10 days after the completion of a treatment cycle. Fatigue is common. Neutropenic fever and infection are common complications of chemotherapy and require immediate treatment. Approximately 10-20% of patients develop excessive neutropenia or an infectious complication. Primary prophylaxis (...) recommended. Rituximab is generally safe. It can cause fever and chills, particularly during the first administration. Rare cases of anaphylactic reactions have been reported. Cases of hepatitis B virus (HBV) reactivation that have resulted in fulminant hepatitis and death have been reported. Persons at high risk of HBV infection should be screened before the initiation of rituximab. Carriers of HBV should be closely monitored for clinical and laboratory signs of active HBV infection and hepatitis during

2014 eMedicine.com

273. Inflammatory Bowel Disease (Follow-up)

TPMT activity, require monitoring for complications. [ ] Adverse effects and monitoring Use of immune modifiers mandates monitoring of blood parameters; they can cause significant neutropenia or pancytopenia that warrants a dose reduction or discontinuation. Routine complete blood cell (CBC) counts with differentials and platelet counts are checked monthly, and liver function tests (LFTs) can be performed intermittently. After a year of stable dosing with no difficulties with blood counts (except (...) . In independent studies, metabolite levels have not shown any correlation with clinical efficacy, but they may help in monitoring compliance. Other adverse effects of the immune modifiers include fever, rash, infectious complications, hepatitis, pancreatitis, and bone marrow depression. The most common reason for discontinuing the immune modifiers within the first few weeks is the development of abdominal pain; occasionally, a biochemically demonstrable pancreatitis occurs. Concerns have been raised about

2014 eMedicine.com

274. Inflammatory Bowel Disease (Follow-up)

TPMT activity, require monitoring for complications. [ ] Adverse effects and monitoring Use of immune modifiers mandates monitoring of blood parameters; they can cause significant neutropenia or pancytopenia that warrants a dose reduction or discontinuation. Routine complete blood cell (CBC) counts with differentials and platelet counts are checked monthly, and liver function tests (LFTs) can be performed intermittently. After a year of stable dosing with no difficulties with blood counts (except (...) . In independent studies, metabolite levels have not shown any correlation with clinical efficacy, but they may help in monitoring compliance. Other adverse effects of the immune modifiers include fever, rash, infectious complications, hepatitis, pancreatitis, and bone marrow depression. The most common reason for discontinuing the immune modifiers within the first few weeks is the development of abdominal pain; occasionally, a biochemically demonstrable pancreatitis occurs. Concerns have been raised about

2014 eMedicine.com

275. Systemic Lupus Erythematosus (Treatment)

function and endothelial repair in clinically stable systemic lupus erythematosus. Lancet . 2015 Feb 26. 385 Suppl 1:S83. . Kamen DL, Oates JC. A Pilot Randomized Controlled Trial of Vitamin D Repletion to Determine if Endothelial Function Improves in Patients With Systemic Lupus Erythematosus. Am J Med Sci . 2015 Sep 7. . Reynolds JA, Haque S, Williamson K, Ray DW, Alexander MY, Bruce IN. Vitamin D improves endothelial dysfunction and restores myeloid angiogenic cell function via reduced CXCL-10 (...) participation in early trials. The SLE Responder Index (SRI) is a tool that was developed following phase II trials and is composed of the following scores [ ] : SELENA-SLEDAI (Safety of Estrogens in Lupus Erythematosus: National Assessment– Systemic Lupus Erythematosus Disease Activity Index) BILAG (British Isles Lupus Assessment Group) PGA (physician global assessment) SRI response is defined by the following [ ] : A 4-point or greater reduction in the SELENA-SLEDAI score No new BILAG A or no more than 1

2014 eMedicine Emergency Medicine

276. Transplants, Liver (Treatment)

is suspected Cultures of blood, urine, pharynx, and/or sputum: Obtain if infection is suspected Imaging studies Chest radiography: Obtain in the presence of fever, cough, dyspnea, or abnormalities on chest examination Abdominal ultrasonography, computed tomography scan, or endoscopic retrograde cholangiopancreatography, as indicated Management of rejection or infection Every clinical complaint by the transplant patient should be taken seriously, and the transplant team should at least know of every (...) dysfunction. Acute rejection is represented clinically as jaundice with laboratory evidence of abnormal liver function tests. Bilirubin and alkaline phosphatase levels rise initially, followed by elevations in the hepatocellular enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Other symptoms may include fever, liver tenderness, and eosinophilia. Acute rejection is most commonly treated with high-dose steroids (prednisolone 200 mg or methylprednisolone 1 g for 3 days) or a high

2014 eMedicine Emergency Medicine

277. Septic Shock (Follow-up)

source of sepsis,” with daily reevaluation of the anti-infective therapy for potential de-escalation. [ , ] Generally, a 7- to 10-day treatment course is followed. Longer treatment regimens may be warranted in the presence of a slow clinical response, undrainable foci of infection, and immunologic deficiencies (eg, neutropenia). The use of procalcitonin or similar biomarkers may facilitate discontinuance of antibiotics in patients with clinical improvement and no further evidence of infection (...) host responses. Source control is an essential component of sepsis management. Venous access In all cases of septic shock, adequate venous access must be ensured for volume resuscitation. When sepsis is suspected, 2 large-bore (16-gauge) intravenous (IV) lines should be placed if possible to allow administration of aggressive fluid resuscitation and broad-spectrum antibiotics. Central venous access is useful when administering vasopressor agents and in establishing a stable venous infusion site

2014 eMedicine.com

278. Breast Cancer Evaluation (Follow-up)

840 mg IV loading dose, then 420 mg q3wk Give with trastuzumab and docetaxel 80.2% (objective response rate) Fever, allergic reaction, cardiotoxicity/congestive heart failure Palbociclib CDK inhibitor 125 mg/day PO for 3 weeks with 1 wk off Give with letrozole Data are not available for ORR Mean PFS was 10.2 months in the letrozole group and 20.2 months for palbociclib plus letrozole group Neutropenia, leukopenia, thrombocytopenia, anemia, stomatitis Ribociclib CDK inhibitor 600 mg/day PO for 3 (...) in women 50 years of age or younger with a recurrence score of 16 to 25, who represented 46% of this age group. [ ] See for summarized information. Next: Treatment of Invasive Breast Cancer Surgical treatment of invasive breast cancer may consist of lumpectomy or total mastectomy. In breast cancer patients who have clinically negative nodes, surgery typically includes sentinel lymph node (SLN) dissection for staging the axilla. (See .) In the AMAROS trial, which involved patients with cT1-2N0 breast

2014 eMedicine.com

279. Breast Cancer (Follow-up)

840 mg IV loading dose, then 420 mg q3wk Give with trastuzumab and docetaxel 80.2% (objective response rate) Fever, allergic reaction, cardiotoxicity/congestive heart failure Palbociclib CDK inhibitor 125 mg/day PO for 3 weeks with 1 wk off Give with letrozole Data are not available for ORR Mean PFS was 10.2 months in the letrozole group and 20.2 months for palbociclib plus letrozole group Neutropenia, leukopenia, thrombocytopenia, anemia, stomatitis Ribociclib CDK inhibitor 600 mg/day PO for 3 (...) in women 50 years of age or younger with a recurrence score of 16 to 25, who represented 46% of this age group. [ ] See for summarized information. Next: Treatment of Invasive Breast Cancer Surgical treatment of invasive breast cancer may consist of lumpectomy or total mastectomy. In breast cancer patients who have clinically negative nodes, surgery typically includes sentinel lymph node (SLN) dissection for staging the axilla. (See .) In the AMAROS trial, which involved patients with cT1-2N0 breast

2014 eMedicine.com

280. Systemic Lupus Erythematosus (Follow-up)

function and endothelial repair in clinically stable systemic lupus erythematosus. Lancet . 2015 Feb 26. 385 Suppl 1:S83. . Kamen DL, Oates JC. A Pilot Randomized Controlled Trial of Vitamin D Repletion to Determine if Endothelial Function Improves in Patients With Systemic Lupus Erythematosus. Am J Med Sci . 2015 Sep 7. . Reynolds JA, Haque S, Williamson K, Ray DW, Alexander MY, Bruce IN. Vitamin D improves endothelial dysfunction and restores myeloid angiogenic cell function via reduced CXCL-10 (...) participation in early trials. The SLE Responder Index (SRI) is a tool that was developed following phase II trials and is composed of the following scores [ ] : SELENA-SLEDAI (Safety of Estrogens in Lupus Erythematosus: National Assessment– Systemic Lupus Erythematosus Disease Activity Index) BILAG (British Isles Lupus Assessment Group) PGA (physician global assessment) SRI response is defined by the following [ ] : A 4-point or greater reduction in the SELENA-SLEDAI score No new BILAG A or no more than 1

2014 eMedicine.com

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