NEUTROPENIA

Dr.Gireesh kumar.K.P
 Causes of neutropenia

• Neutropenia can result from three major mechanisms:

 Low neutrophil production/differentiation in bone marrow
(eg, drug-associated, infection, nutritional deficiency)
 Redistribution of circulating neutrophils to the vascular
endothelium ("margination") or to the spleen
 Immune destruction (eg, drug reaction, autoimmunity)
Neutropenia can be categorized as

• Mild – ANC ≥1000 and <1500 cells/ mm3

• Moderate – ANC ≥500 and <1000 cells/ mm3
• Severe – ANC <500 cells/ mm3
• Agranulocytosis – ANC <200 cells/ mm3

• ANC = WBC (cells/mm3) x percent (PMNs  +  bands) ÷

100
Acquired neutropenia
• Infections - Tuberculosis, typhoid fever, brucellosis, measles, infectious
mononucleosis, viral hepatitis, leishmaniasis, viral fevers, AIDS
• Drug induced –
• Neutropenia associated with autoimmune disorders(SLE,RA)
• Autoimmune Neutropenia
• Tumor invasion of bone marrow , myelofibrosis
• Nutritional deficiency—vitamin B12, folate (especially alcoholics)
• Benign familial neutropenia
• Chronic benign neutropenia of childhood
• Chronic idiopathic neutropenia
• Neutropenia associated with metabolic diseases
• Neutropenia due to increased margination
Intrinsic defects
• Cyclical neutropenia ,Chediak-Higashi syndrome
• Myelokathexis/neutropenia with tetraploid nuclei
• Shwachman-Diamond-Oski syndrome
• Kostmann syndrome (severe infantile agranulocytosis)
• Reticular dysgenesis
Clinically Significant Neutrophil Counts

ANC Clinical Significance

>1,500/mm3 Normal
1,000-1,500 Less chances for infection
500-1,000 Possibility of infection.
<500 High chances of infection.
Few clinical signs of infection may present .
Treatment with IV antibiotics.

<200 The inflammatory process will be absent.

ANC; Absolute Neutrophil Counts
Bone marrow study 

• The gold standard for diagnosing the ability of bone

marrow to produce neutrophils is by examination of a
bone marrow aspirate and marrow biopsy specimen.
Bone marrow neutrophil production is considered to be
adequate if the cellularity and maturation of the neutrophil
series is normal or increased. In contrast, reduced bone
marrow cellularity or myeloid arrest at the myelocyte or
metamyelocyte stage indicates decreased bone marrow
ability.
Management


Rigorous oral hygiene - Oral antifungal agents,
Chlorhexidine mouth wash

To prevent infections - Oral trimethoprim-
sulfamethoxazole (160/800 mg) BD

During fever – Anti pseudomonas / MRSA antibiotic
agents – Ceftazidime / Piperacilline - Tazobactum +
Vancomycin to cover infection from skin

Colony stimulating factors ( CSF )
Colony stimulating factors ( CSF )
 Granulocyte CSF ( G-CSF ) - Filgrastim (Grafeel ®,Neupogen ® ) 5 mcg/kg /day SC injection
 GM-CSF is used to stimulate the production of white blood cells following chemotherapy / drug induced
neutropenia.
 The duration of treatment is usually 14 days, or Continue until absolute neutrophil count is 10,000//
mm3
 Filgrastim is also indicated for reducing the time to neutrophil recovery and the duration of fever,
following induction or consolidation chemotherapy treatment of adults with AML.
 Cancer Patients Receiving Bone Marrow Transplant - The recommended dose of filgrastim following
BMT is 10 mcg/kg/day given as an IV infusion of 4 or 24 hours‚ or as a continuous 24-hour SC infusion.
• GM-CSF – Molgramostim(GM-CSF), sargramostim
ANC: absolute neutrophil count; C. difficile: Clostridium difficile.