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THE MANAGEMENT OF FEVER: EVALUATION OF THE FEBRILE NEUTROPENIC CHILD WITH CANCER
A. History and physical examination
The evaluation of the febrile child with cancer should be thorough but expeditious. If the patient is neutropenic, remember that sometimes only faint clues of the inflammatory process will be present, such as minimal discharge, faint tenderness, or redness. Pay special attention to the skin, nose, pharynx, and perineal and perirectal areas. Palpate over sinuses and range of motions in all joints. The identification of an infection in specific areas, such as the perirectum, skin, or mouth, narrows the spectrum of likely infecting microorganisms.
B. Laboratory evaluation
Laboratory evaluation should include a complete blood count, urinalysis, and generous amounts of blood drawn from all venous access catheter ports and one or two peripheral sites for culture. A catheter site that is inflamed or draining should be cultured. Any suspicious skin lesion, watery blister, or prominent erythema should be aspirated, stained, and cultured. If periodontal infection is suspected, the patient should be examined by a pediatric dentist and appropriate radiographs and tissue samples obtained. Patients with tenderness over a sinus(es) should have diagnostic imaging studies. A febrile, neutropenic child with cancer who demonstrates mental confusion or central nervous system dysfunction should have a lumbar puncture.
Examine diarrheal stools for bacterial, protozoal, and viral agents and Clostridium difficile toxin. Culture urine if there are signs of urinary tract infection, the urinalysis is abnormal, or a urine catheter is in place. Chest radiographs are indicated if there are clinical symptoms or signs suggesting pulmonary disease.
C. Other studies (optional)
1. Phase reactants
Although available to some only as research tools, C-reactive protein, interleukin-6, and serum amyloid A acute inflammatory response indicators may give a rapid indication of bacteremia or bacterial infection.
2. Radiolabeled imaging
To help locate occult site of infection, indium-111-Iabeled donor granulocytes and indium-111-labeled immunoglobulin may be useful.
3. Special studies
The polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) may be helpful in the early diagnosis of invasive bacterial or fungal disease. Candida enolase antigenemia can detect invasive fungal disease.
D. Follow-up monitoring
Reexamine and reevaluate patients carefully at least once a day. Obtain blood cultures at least daily while the patient is febrile. Repeat urine, stool, tissue cultures, obtain diagnostic imaging, and consultation as clinically indicated.
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Cancer