Dr. Kiefer presented a thought provoking case of a patient with chronic saccular bronchiectasis who presented with agranulocytosis and fevers! Let’s review:
What’s agranulocytosis? I remember learning that in med school…
It’s when neutrophilia gets bad:
Mild: Absolute neutrophil count (ANC) <1500
Moderate: ANC 500-1000
Severe: ANC <500 *
Agranulocytosis: ANC<200 **
* ANC <500 + fever (T>38.2 OR >38 degrees for greater than an hour) is neutropenic fever
** Agranulocytosis is caused by medications up to 70% of the time (most commonly: sulfasalazine, TMP-SMX, methimazole (these three are responsible for up to 42% of cases). Other ones on the list include NSAIDs, macrolides, vancomycin (Commonly USED ones just to keep in mind).
Figure 1: Algorithm for the evaluation and treatment of adult patients with neutropenia ( Gibson, C., & Berliner, N. (2014). How we evaluate and treat neutropenia in adults. Blood, 124(8), 1251-1258. Accessed August 11, 2019.https://doi.org/10.1182/blood-2014-02-482612.)
Ok, now how do I think about etiologies of bronchiectasis?
Very briefly, we can categorize conditions associated with bronchiectasis into the following categories: Post-infectious, congenital conditions, immunodeficiencies, sequelae of toxic inhalation/aspiration, rheumatologic conditions.
Please refer to this review article by our very own Alan Barker, MD for details!
Barker, A. (2002). Bronchiectasis. N Engl J Med, 346:1383-1393