zaki
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You are called in consultation by an emergency room physician for a 65-year-old man with a severe sore throat and fever. The patient has chronic congestive heart failure and has been taking several cardiac drugs for 2 months. Physical examination shows an irregular, rapid pulse, a blood pressure of 110/70 mm Hg, and a temperature of 39 °C (102.2 °F). The pharynx is inflamed. Both S3 and S4 gallops are present. A complete blood count shows a hemoglobin of 12 g/dL, absolute neutrophil count of 100/µL, and platelet count of 190,000/µL. The patient resides in a rural area and refuses transfer to a referral center for further invasive studies, including bone marrow examination.
In addition to discontinuing all drugs that may cause neutropenia, which of the following is the most appropriate course of action to advise the attending internist?
A)No additional action can be recommended in the absence of a bone marrow examination
B)Initiate corticosteroids
C)Prescribe an antibiotic with activity directed to throat flora, and treat the patient out of the hospital to avoid nosocomial infections.
D)Transfer the patient to an intensive care unit and begin immediate treatment with granulocyte colony-stimulating factor (G-CSF).
E)Admit to the hospital, and begin treatment with intravenous broad-spectrum antibiotics
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Maverick
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| mahendra
Forum Guru
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i think its D?
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| Yulia
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i am going with e - admit this pt and give him iv antibiotics.
g-csf is not indicated in this case, where neutropenia is probably caused by one of the medication pt taking, the right thing is to see if it goes away after offending drug is stopped.
a is wrong, he clearly needs antibiotics
corticosteroids are not going to do any good in neutropenic pt having a fever. b is wrong
this pt has to be admitted, so c is incorrect.
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| mahendra
Forum Guru
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you r right.
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E i think is right
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| zaki
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E is right
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Maverick
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| zaki
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The patient has drug-induced agranulocytosis. A sudden, severe, and isolated fall in neutrophil count in a patient on polypharmacy strongly suggests agranulocytosis, which is mainly drug-associated. Evaluation of the bone marrow is useful to discriminate agranulocytosis from other causes of severe neutropenia, especially myelodysplasia and leukemia in the elderly. Typically, myeloid precursor cells are absent, but myeloblasts and promyelocytes may be present in some cases and in early convalescence. However, the clinical setting is usually so suggestive that appropriate treatment should not wait on the results of the bone marrow examination.
Captopril and procainamide are the most likely suspects in a patient with chronic cardiac disease, and these should be discontinued. Even though an immune mechanism is often responsible for drug-associated agranulocytosis, corticosteroid therapy is contraindicated in the presence of neutropenia. Although ultimate recovery is to be expected, the mortality rate remains high - about 10% - because patients succumb to overwhelming bacterial infection. Immediate treatment with broad-spectrum antibiotics by a parenteral route is absolutely indicated in a patient with fever and severe neutropenia. Even in the presence of localizing signs, more restricted antibiotic therapy is perilous because of the possibility of polybacterial sepsis or infection with an unusual organism. Patients with neutropenia are almost always infected with endogenous organisms from their own gut, nasopharynx, or skin; hospitalization, rather than posing a risk, is strongly indicated in this critically ill patient. Hematopoietic growth factor therapy, although of unproven benefit in agranulocytosis, may accelerate recovery and is unlikely to be harmful.
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Maverick
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