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Investigation and management of a child who is immunocompromised and neutropoenic with pulmonary infiltrates
  1. S Wilson1,
  2. R Grundy2,
  3. H Vyas1
  1. 1
    University Hospital, Queens Medical Centre, Nottingham, UK
  2. 2
    Children’s Brain Tumour Research Centre, Institute of Child Health, University of Nottingham, Nottingham, UK
  1. Correspondence to Professor H Vyas, University Hospital, Queens Medical Centre, Nottingham, NG72UH; harish.vyas{at}nuh.nhs.uk

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Paediatric neutropoenia encompasses a vast range of congenital and acquired causes. Postinfectious neutropoenia represents the most common cause of acquired isolated neutropoenia.1 Neutropoenia following viral infections tend to be brief and usually resolve spontaneously without any serious side effects. These patients therefore do not have the same risk of sepsis and pulmonary complications as those patients with aplastic anaemia, congenital immunodeficiencies or those treated for cancer associated with neutropoenia. In the latter group pancytopoenia may be prolonged resulting in an increased risk of bacterial, viral, fungal and parasitic infections. Bone marrow failure occurs due to the disease process or following myelotoxic chemotherapy, irradiation and post haematopoeitic stem cell transplant (HSCT).

Advances in the treatment and supportive care for childhood cancer have resulted in the expected outcome being one of cure. However, in the intervening period the complications arising from neutropoenia may contribute to a significant morbidity and mortality. Pulmonary infiltrates make up a significant percentage of these complications.2 3 We present an overview of the many causes of pulmonary infiltrates in patients who are neutropoenic, and an approach to diagnosis and management.

Pathophysiology

  • Neutrophils are the body’s major defence against bacterial and fungal infections. Patients with cancer have quantitative immunodeficiencies and qualitative abnormalities as well. Treatment and disease-related cytopoenias predispose to non-specific immunodeficiencies (eg, neutropoenia). Other cellular components (eg, macrophages and lymphocytes) may be depleted and humoral immunodeficiencies may also coexist.

  • The risk of sepsis is directly proportional to the degree of neutropoenia and its duration. Patients with circulating neutrophils >1.0×109/litre have a normal protective response. The risk increases with progressive neutropoenia being greatest when the neutrophil count is below 0.2×109/litre and lasting more than 14 days.4

  • Patients are often colonised by resistant organisms and chemotherapy-induced mucosal destruction predisposes to invasive sepsis.5

  • In …

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