Neutropenic Fever

When I finished this latest round of chemotherapy I was really hopeful that I would be able to avoid a hospital visit.  I was hospitalized once during the last round for Neutropenic Fever and actually was unable to have the last treatment of chemotherapy.  I had been on a cycle of one treatment a week for three weeks and then one week off the first time around which ended in April 2010.  This time it was four treatments of Adriamycin and Cytoxan given once a month and ending January 2011.

On Monday I began having diarrhea and cold chills.  As instructed, I checked my temperature and initially it was only 99.1 degrees Fahrenheit.  I got into bed with the heating pad around 2 pm praying fervently that a little rest would take care of things.  I reached into my purse and pulled out my medication information which lists symptoms and suggestions on what to do if you show any.  It very clearly states that a fever of 100.5 and chills are a sign of possible infection and that I should call my doctor immediately day or night if I show signs of these symptoms (additionally blistering at the IV site and Shortness of breath or swelling of throat or facial features).  I have gotten in some hot water on past occasions for not calling as this is a sign of a serious problem.

It is also very vital to pay attention to these symptoms at the nadir (low point) of the blood counts occurring between 7-14 days after treatment.  January 31, 2011 was exactly 7 days following my last treatment so it wasn't something that I could just ignore. By 4 pm my temperature was up to 100 degrees Fahrenheit and I called my friend who is an oncology nurse and consulted with her.  Upon seeing there was no way to avoid a phone call to Dr. Matei I then placed a call to her.  Dr. Matei was unhappy that I had waited until around 4:30 pm to call and wished I had called sooner.  She instructed me to go to the Emergency Room.  I asked her for a direct admit and she told me that it was too late in the afternoon.  I then received a quick call back from her and was instructed to go to Penrose Main and go directly to the 11th floor.

I was admitted and placed on IV antibiotics for Neutropenic Fever.  If you look this up on the Internet you will find that this is a common result of being on chemotherapy.  I was released the following day when the temperatures were at record lows in Colorado and the rest of the country. I consider myself very lucky to have been released so soon as I did a five day stretch last time.

Fever, Neutropenic Fever, and their Relationship to Chemotherapy

What is fever and can it be caused by chemotherapy or other cancer treatments? 
Fever is an abnormally high body temperature.  Usually defined by 3 oral temperatures greater than 38ºC or 100.4ºF in a 24-hour period, or one temperature greater than 38.5ºC or 101.3ºF.  Fever is the body's response to infection.  However, only in about half of all patients with cancer, who develop a fever, can a definite source of the infection be found.

Fever is particularly concerning if it occurs at a time when the white blood count level is known or expected to be low (at the nadir).  During this time the body's normal defenses against infections are down, and fever needs to be further evaluated immediately.

Chemotherapy and fever are sometimes related because fever can also be present in patients who are receiving chemo treatments and biologic therapy as part of the "flu-like syndrome (FLS)."  The fevers associated with FLS usually peak at 40ºC or 104ºF and often spike after a severe chill.  This can mimic the clinical picture of sepsis (an infection in the blood), so it is important that patients who are receiving biologic therapy to be aware of the usual course of fever after treatment. 
How is fever evaluated?
Physical exam and history of symptoms:

• Questions as to whether there are any other signs of infection, redness, swelling, pain, pus, productive cough, color of phlegm, breaks in the skin, presence of an IV line, mouth sores. 
• Questions as to when last chemotherapy was given and what type of chemotherapy was given.  This gives the health care professional an idea whether the patient is likely to be neutropenic.

Characteristics and symptoms of neutropenic fever:

• When a person is neutropenic (has low white blood cells or neutrophils) the usual signs of infection (redness, swelling and pus formation) are absent. Pain and tenderness may be the only other indicators of infection.
• If a patient is taking biologic therapy where fever is a likely side effect of the treatment knowing the timing of the fever and it's association with the treatment will help to evaluate if infection may also be present.

Lab tests:

• Complete blood count (CBC) may be checked to see if a patient is neutropenic (low white blood cell count) and at higher risk of infection.
  • If a patient has a fever and low neutrophil count (less than 500/mm3) (febrile neutropenia) they are at risk for infection they may be hospitalized, monitored and receive antibiotics.  The concern is that an infection can develop in the blood and lead to a life-threatening condition - sepsis.  So the patient is admitted to receive antibiotics until the fever resolves, and neutrophils increase to safe levels - if no source of infection is found.
• Cultures to try to determine the source of infection from:
  • Blood
  • Urine
  • Throat
  • Drainage from catheter or draining wound. 
  • If diarrhea is present in a neutropenic patient a sample may be checked.

Chest X-ray (CXR):

• This is a quick and painless procedure where a picture, or an x-ray, will be taken to look at the internal structures of your chest. The chest x-ray will look specifically at your lungs, heart, and ribs. 
• When infection is suspected CXR are often repeated to compare one to another.  Sometimes this is more helpful to detect subtle changes especially in patients with prolonged neutropenia (low neutrophil counts).

Things you can do to minimize the effects of fever:

Fever related to febrile neutropenia/infection:

• Notify your health care professional immediately if you have a fever greater than 38.5ºC or 100.5ºF.
• Know what chemotherapy drugs you are receiving (write them down) and if they are likely to cause low white blood cell counts.  This will help if you develop a fever on an evening or weekend and need to talk to a health professional who is not familiar with your case.
• If you are receiving chemotherapy that is likely to decrease your white blood cell count, check your temperature twice a day if you feel warm.