Thanks Mario for a great case! This is a case of a young patient with alpha-1-anti-trypsin deficiency cirrhosis, recently started on diuretics who was found to have profound neutropenia and pancytopenia thought secondary to furosemide.
1) For the differential diagnosis of pancytopenia, a good approach is thinking in broad categories: infection, malignancy, autoimmune, nutritional deficiency, medications/ toxins, marrow suppression/ aplastic anemia
2) Neutropenic fever is defined as a temp of 38 for > 1 hour or 38.3 one time in conjunction with an ANC of 500 or less (or ANC less than 1000 trending to < 500 in the next day)
3) Drug induced neutropenia/ pancytopenia has a long list of culprits. Micromedex sometimes is a good tool to use to search for references of case reports.
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Differential for leukopenia/ neutropenia
Here is a starting point for the differential for leukopenia/ neutropenia:
- inflammatory: Felty syndrome (leukopenia, splenomegaly, RA, leg ulcers), SLE, sjogren syndrome, levamisole vasculitis
- infection: MRSA pneumonia, typhoid, TB, RMSF, CMV, MAC, anaplasmosis, parvo B19 infection, histoplasmosis, dengue fever
- malignancy: leukemia, lymphoma, multiple myeloma
- meds: methotrexate, valganciclovir, MMF, colchicine, interferon, vancomycin, drug induced megaloblastic anemia (many drugs), chemotherapy
- other: alcoholism, cirrhosis, kikuchi-fujimoto (histiolytic necrotizing lymphadenitis)
- Here is a great Blood “How I treat” article for neutropenia
- IDSA has great guidelines for treatment of both inpatient and outpatient neutropenic fever in patients with cancer
- remember to search broadly for infection since there won’t be enough neutrophils often to localize infection, consider imaging broadly, doing an oropharyngeal exam, skin exam and have a lower threshold to obtain a CT-chest if the patient has pulmonary symptoms with a clear CXR