Neutropenia


Article Author:
Angel Justiz Vaillant


Article Editor:
Patrick Zito


Editors In Chief:
Mohamed Alhajjaj
Fatima Anjum
Pramil Cheriyath


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
2/22/2019 6:42:55 PM

Introduction

Neutrophils play an essential role in immune defenses because they ingest, kill and digest invading microorganisms, including fungi and bacteria. Failure to carry out this role leads to immunodeficiency that is mainly characterized by the presence of recurrent infections.[1] Defects in neutrophil function can be quantitative as seen in neutropenia or qualitative as seen in neutrophil dysfunction. The standard circulating neutrophil count is above 1.5 x 10/L. Neutropenia can be classified in asymptomatic (mild), moderate and severe and thus the progression to infection concerning the number.

Neutropenia with decreased production with marrow hypoplasia can be primary and due to chronic benign neutropenia, cyclical neutropenia and other congenital and familial neutropenias. It can be secondary to cytotoxic drugs, aplastic anemia, leukemia, drug reactions, and infections. Neutropenia with increased destruction with marrow hyperplasia is due to hypersplenism and immune neutropenia. Secondary causes are the commonest, for example, neutropenia caused as a side effect of chemotherapy for malignancies. Congenital forms are rare and vary in severity, some of them are life-threatening conditions including leukocyte adhesion deficiency, Chediak-Higashi syndrome, hyper-IgE, recurrent infection syndrome, and chronic granulomatous disease.[2][3]

Etiology

The causes of primary defects of neutrophil function include failure of the following[3][4]:

  • Adhere to endothelial cells
  • Migrate into inflammation sites (abnormal chemotaxis)
  • Ingest and kill bacteria
  • Produce microbicidal compounds to kill fungi and other pathogens
  • Form phagolysosomes
  • Make high concentrations of toxic reactive oxygen species

Epidemiology

Hsieh and collaborators reported that in the United States, the prevalence of neutropenia was 0.38% among Mexican-Americans, 0.79% among whites, and 4.5% among black participants.[5] Weycker and collaborators reported that the risk of febrile neutropenia during the chemotherapy regimen course for treating solid tumor was 16.8%.[6] Severe neutropenia was present in 1 of every 2 patients with lymphoma receiving chemotherapy with a higher risk of febrile neutropenia, and it was found in approximately 1 of every 10 breast cancer patients in Spain.[7]

Pathophysiology

Neutrophils play a role in the immune defense against extracellular bacteria including Staphylococci, Streptococci, Escherichia coli among others. They also protect against fungal infections including those produced by Candida albicans. Once their count is below 1 x 10/L recurrent infections start. As compensation, the monocyte count may increase. In primary neutropenia disorders such as chronic granulomatous disease presents with recurrent infections affecting many organs since childhood. It is caused from a failure to produce toxic reactive oxygen species so that the neutrophils can ingest the microorganisms but they are unable to kill them, as a significant consequence granuloma can obstruct organs such as the stomach, esophagus, or bladder. Patients with this disease are very susceptible to opportunistic infections by certain bacteria and fungi, especially with Serratia and Burkholderia.[8]

Leukocyte adhesion deficiency has an autosomal recessive inheritance, and its functional defect is a failure of neutrophils to adhere to endothelial cells and so to traverse into tissues to ingest and kill bacteria. Chediak-Higashi syndrome is also an autosomal recessive problem, characterized by abnormal chemotaxis, so neutrophils fail to reach bacteria, and reduced microbicidal activity as lysosomes fail to fuse with phagosomes.[9]

Histopathology

In Chediak-Higashi syndrome histologically present with giant lysosomal granules in secretory cells.[9] The chronic granulomatous disease is characterized by the presence of granulomas, which are composed by histiocytes that can fuse to form multinucleated giant cells and might be surrounded by other immune cells such as lymphocytes and cover with collagen.

History and Physical

In neutropenia there is a history of[9][10][11]:

  • Recurrent infections
  • Infections caused by rare bacteria and fungi
  • Opportunistic infections
  • Frequent use of antibiotics and antifungals

The physical findings include[12][10][9][13][14]:

  • Delayed separation of umbilical cord
  • Skin infections
  • Gingivitis
  • Deep abscesses
  • Peritonitis
  • Osteomyelitis
  • Lung abscesses
  • Pneumatoceles
  • Sinus and lung infections, e.g., pneumonia
  • Otitis media
  • Meningitis
  • Septicemia
  • Arthritis
  • Bacteremia
  • Fever
  • Coarse facial features
  • Mucocutaneous candidiasis
  • Cough
  • Malaise
  • Intestinal malabsorption
  • Bronchiectasis
  • Recurrent tonsillitis
  • Extensive cutaneous bacterial (Staphylococcal) infections
  • Sore throat
  • Purulent conjunctivitis
  • Granuloma with catalase-positive organisms
  • Skin abnormalities, e.g., pyodermitis
  • Splenomegaly 
  • Diarrhea    
  • Recurrent abscess       
  • Aphthous stomatitis
  • Urinary sepsis
  • Vasculitis
  • Poor wound healing  

Evaluation

The immunological investigation of a patient with neutropenia includes the assessment of immunoglobulins, complement system, and phagocytes.[15][16]

Quantitative Serum Immunoglobulins

  • IgG
  • IgM
  • IgA
  • IgE

Blood Lymphocyte Subpopulations

  • B lymphocytes (CD19 and CD20)

Phagocytic Function  

Nitroblue tetrazolium (NBT) test (before and after stimulation with endotoxin)

  • Unstimulated
  • Stimulated

Neutrophil mobility

  • In medium alone
  • In presence of chemoattractant

Complement System Evaluation

Measurement of individuals components by immunoprecipitation tests, ELISA, or Western blotting

  • C3 serum levels
  • C4 serum levels

Hemolytic assays

  • CH50

Complement system functional studies

  • Classical pathway assay (using IgM on a microtiter plate)
  • Alternative pathway assay (using LPS on a microtiter plate)
  • Mannose pathway assay (using mannose on a microtiter plate)

Microbiological studies

  • Blood culture
  • Urine culture
  • Stool culture 
  • Sputum culture
  • Cerebrospinal fluid (culture, chemistry, and histopathology)

Other investigations of immunodeficiency disorders 

  • Complete blood cell count    
  • Bone marrow biopsy
  • Histopathological studies
  • Blood chemistry
  • Tumoral markers
  • Levels of cytokines (granulocyte-colony stimulating factor)
  • Chest x-ray
  • Diagnostic ultrasound
  • CT scan
  • Fluorescent in situ hybridization (FISH)
  • DNA testing (for most congenital disorders)

Treatment / Management

Application of granulocyte-colony stimulating factor (G-CSF) can improve neutrophil functions and number.[17][7] Prophylactic use of antibiotics and antifungals is reserved for some forms of alteration in neutrophil function such as chronic granulomatous disease CGD).[13][18] The utilization of antimicrobials is compulsory if recurrent infections exist. Interferon-gamma has been successfully used to improve the quality of life of the patient suffering from neutropenia. Allogenic bone marrow transplantation from an HLA-matched related donor can cure CGD but has a high mortality rate,[19] and gene therapy is also a therapeutic option for treating disorders with neutropenia. Furthermore, intravenous immunoglobulins can be another option in the management of these disorders.[13]

Differential Diagnosis

Neutropenia can differentiate from antibody deficiency disorders, where a class or different classes of immunoglobulins are below the normal range or absence. These disorders may present clinically by recurrent infections with bacteria and fungi, some of them are opportunistic pathogens, so the use of antimicrobials to treat infectious diseases is a norm.[20] A patient with neutropenia may have an intact acquired immune response but a low number or impaired function of neutrophils. Some complement system deficiency, e.g., C3 deficiency manifests with multiple extracellular bacterial infections and may resemble neutropenia, but can rule out by quantification and functional assessment of the complement system.[1][21]

Prognosis

The prognosis of neutropenia disorders base on the cause and organs involved. CGD has a better prognosis if allogenic bone marrow transplantation can successfully achieve. Neutropenia due to chemotherapy or drugs may cause remission once the treatment is over. Some primary defects of neutrophil functions affect the prognosis, where devastating fatal diseases can lead to death in young age.[22]

Complications

  • Recurrent and fatal bacterial and fungal infections[13]
  • Bacteremia
  • Septic shock
  • Premature death
  • Failure to thrive
  • Protein-energy malnutrition
  • Multi-organ failure

Enhancing Healthcare Team Outcomes

An interprofessional team manages the patients with neutropenia including physicians, nurses and different technologist as a phlebotomist. A specialist in infectious diseases, internal medicine specialist or pediatrician could recommend several treatment options including antibiotics and antifungal. A patient with severe neutropenia is considered to have a life-threatening disorder and should be monitored regularly for complete blood cell count, blood chemistry, infectious disease markers, and immunotherapy. The use of neutrophil colony-stimulating factor should be monitored by an immunologist or hematologist to treat the side effects of this cytokine efficiently.


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Neutropenia - Questions

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What is the first step in managing a febrile patient who is neutropenic?



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Which of the following is the best treatment for chemotherapy associated neutropenia?



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A 25-year-old male, who has been HIV positive for about 8 years, is admitted to the hospital with respiratory distress. The patient had focal neurological deficits earlier and now is in a comatose state. The pulmonary and central nervous system biopsies show dichotomously branching septate hyphae. What is the most likely underlying condition?



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What is the absolute neutrophil count in cells per microliter based on the patient's complete blood count and differential pictured?

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    Contributed by Scott H. Plantz, MD, FAAEM
Attributed To: Contributed by Scott H. Plantz, MD, FAAEM



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A 2-year-old male presents with recurrent pneumonia and otitis media mainly caused by staphylococci and streptococci. The opsonophagocytic index is below the normal range, and there is a lack of phagolysosomes in the cytoplasm of neutrophils. Other immunological tests are unremarkable. What is the most likely diagnosis?



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In which of the following ways does neutropenia resemble antibody deficiency disorders?



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A 3-year-old male with has a history of recurrent deep abscesses and otitis media caused by pyogenic bacteria. Laboratory findings include a hemoglobin of 6 grams/dL, leukocytes 4000 cells/microliter, neutrophil count 400 cells/microliter, and platelet count 145,000 platelets/microliter. What is the best option to treat this patient?



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A patient with neutropenia is about to be discharged. Which of the following instructions should be included? Select all that apply.



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What food is safest for a neutropenic client to eat? Select all that apply.



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Neutropenia - References

References

Evaluation of a Risk-guided Strategy for Empiric Carbapenem Use in Febrile Neutropenia., Khoo AL,Zhao YJ,Teng M,Ying D,Jin J,Chee YL,Poon LM,Lim SE,Koh LP,Chng WJ,Lim BP,Hsu LY,Ann Chai LY,, International journal of antimicrobial agents, 2018 May 8     [PubMed]
Myeloid-derived suppressor cells (MDSCs) in patients with solid tumors: considerations for granulocyte colony-stimulating factor treatment., Pilatova K,Bencsikova B,Demlova R,Valik D,Zdrazilova-Dubska L,, Cancer immunology, immunotherapy : CII, 2018 May 10     [PubMed]
Incidence, treatment, and consequences of chemotherapy-induced febrile neutropenia in the inpatient and outpatient settings., Weycker D,Barron R,Kartashov A,Legg J,Lyman GH,, Journal of oncology pharmacy practice : official publication of the International Society of Oncology Pharmacy Practitioners, 2014 Jun     [PubMed]
Prevalence of neutropenia in the U.S. population: age, sex, smoking status, and ethnic differences., Hsieh MM,Everhart JE,Byrd-Holt DD,Tisdale JF,Rodgers GP,, Annals of internal medicine, 2007 Apr 3     [PubMed]
Incidence of chemotherapy-induced neutropenia and current practice of prophylaxis with granulocyte colony-stimulating factors in cancer patients in Spain: a prospective, observational study., Jolis L,Carabantes F,Pernas S,Cantos B,López A,Torres P,Funes C,Caballero D,Benedit P,Salar A,, European journal of cancer care, 2013 Jul     [PubMed]
Clinical, laboratory and molecular signs of immunodeficiency in patients with partial oculo-cutaneous albinism., Dotta L,Parolini S,Prandini A,Tabellini G,Antolini M,Kingsmore SF,Badolato R,, Orphanet journal of rare diseases, 2013 Oct 17     [PubMed]
Clinical manifestations and outcomes of pediatric chronic neutropenia., Wan C,Yu HH,Lu MY,Lee JH,Wang LC,Lin YT,Yang YH,Chiang BL,, Journal of the Formosan Medical Association = Taiwan yi zhi, 2012 Apr     [PubMed]
Skin manifestations in primary immunodeficient children., Al-Herz W,Nanda A,, Pediatric dermatology, 2011 Sep-Oct     [PubMed]
Accelerated phase of chediak higashi syndrome mimicking lymphoma--a case report., Nargund AR,Madhumathi DS,Premalatha CS,Rao CR,Appaji L,Lakshmidevi V,, Journal of pediatric hematology/oncology, 2010 Aug     [PubMed]
Neutropenia and primary immunodeficiency diseases., Rezaei N,Moazzami K,Aghamohammadi A,Klein C,, International reviews of immunology, 2009     [PubMed]
Severe congenital neutropenia: new genes explain an old disease., Bohn G,Welte K,Klein C,, Current opinion in rheumatology, 2007 Nov     [PubMed]
Chediak-Higashi syndrome: four cases from Northern Finland., Möttönen M,Lanning M,Baumann P,Saarinen-Pihkala UM,, Acta paediatrica (Oslo, Norway : 1992), 2003 Sep     [PubMed]
Prevention of Infectious Complications in Patients With Chronic Granulomatous Disease., Slack MA,Thomsen IP,, Journal of the Pediatric Infectious Diseases Society, 2018 May 9     [PubMed]
Allogeneic Hematopoietic Cell Transplantation for Chronic Granulomatous Disease: Controversies and State of the Art., Connelly JA,Marsh R,Parikh S,Talano JA,, Journal of the Pediatric Infectious Diseases Society, 2018 May 9     [PubMed]
Chronic Granulomatous Disease: Epidemiology, Pathophysiology, and Genetic Basis of Disease., Rider NL,Jameson MB,Creech CB,, Journal of the Pediatric Infectious Diseases Society, 2018 May 9     [PubMed]
Efficacy of recombinant human granulocyte-colony stimulating factor alone and in combination with antifungal agents against disseminated trichosporonosis in neutropenic mice., Perparim K,Hashimoto A,Nasu M,, Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy, 1996     [PubMed]
Immunodeficiency, Justiz Vaillant AA,Qurie A,,, 2018 Jan     [PubMed]
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Afzali P,Isaeian A,Sadeghi P,Moazzami B,Parvaneh N,Robatjazi M,Ziaee V, Complement deficiency in pediatric-onset systemic lupus erythematosus. Journal of laboratory physicians. 2018 Apr-Jun;     [PubMed]
García de Guadiana-Romualdo L,Cerezuela-Fuentes P,Español-Morales I,Esteban-Torrella P,Jiménez-Santos E,Hernando-Holgado A,Albaladejo-Otón MD, Prognostic value of procalcitonin and lipopolysaccharide binding protein in cancer patients with chemotherapy-associated febrile neutropenia presenting to an emergency department. Biochemia medica. 2019 Feb 15;     [PubMed]
Zermatten MG,Koenig C,von Allmen A,Agyeman P,Ammann RA, Episodes of fever in neutropenia in pediatric patients with cancer in Bern, Switzerland, 1993-2012. Scientific data. 2019 Jan 15;     [PubMed]
Wuyts L,Wojciechowski M,Maes P,Matthieu L,Lambert J,Aerts O, Juvenile ecthyma gangrenosum caused by Pseudomonas aeruginosa revealing an underlying neutropenia: case report and review of the literature. Journal of the European Academy of Dermatology and Venereology : JEADV. 2019 Jan 11;     [PubMed]

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