Domain – Haematological presentations (guiding topics)

• Interpret and further evaluate common haematologic investigations:
  • low and high haemoglobin levels
  • leucocytosis with neutrophilia
  • leucocytosis with lymphocytosis
  • isolated thrombocytopenia
  • high ESR
  • high ferritin with high transferrin saturation
  • low ferritin with low iron levels and low transferrin saturation
  • deranged liver function tests with high ferritin levels
  • raised protein levels with reversal of albumin globulin ratio
  • thrombocytopenia in an adult and a child
  • macrocytosis
  • haematological abnormalities in different infectious diseases like Epstein–Barr virus (EBV), acute human immunodeficiency virus (HIV).

Condition	Description	Potential Causes
Low Hemoglobin Levels	Anemia	Nutritional deficiencies (iron, B12, folate), chronic diseases, bone marrow disorders, blood loss
High Hemoglobin Levels	Polycythemia or elevated red cell mass	Polycythemia vera chronic hypoxia (COPD) high-altitude living dehydration
Leukocytosis with Neutrophilia	Increased white blood cells with predominance of neutrophils	Bacterial infections inflammation stress response myeloproliferative disorders
Leukocytosis with Lymphocytosis	Increased white blood cells with predominance of lymphocytes	Viral infections (EBV, CMV, HIV) chronic inflammatory conditions chronic lymphocytic leukemia (CLL)
Isolated Thrombocytopenia	Reduced platelet count	Immune thrombocytopenia (ITP) drug-induced thrombocytopenia bone marrow suppression infections (dengue, HIV) splenic sequestration
High ESR (Erythrocyte Sedimentation Rate)	Elevated rate at which red blood cells settle in a period of one hour	Inflammatory conditions, infections, autoimmune diseases, malignancies
High Ferritin High Transferrin Saturation	Increased iron storage and transport	Hemochromatosis iron overload due to multiple transfusions liver disease
Low Ferritin Low Iron Levels Low Transferrin Saturation	Iron deficiency	Iron deficiency anemia chronic blood loss poor dietary intake
Deranged Liver Function Tests with High Ferritin Levels	Abnormal liver enzymes with increased iron storage	Liver diseases (hepatitis, cirrhosis), hemachromatosis
Raised Protein Levels with Reversal of Albumin/Globulin Ratio	Increased total protein with more globulins than albumin	Chronic infections, liver disease, multiple myeloma
Thrombocytopenia in an Adult	Reduced platelet count	ITP, drug-induced bone marrow suppression infections splenic sequestration
Thrombocytopenia in a Child	Reduced platelet count	ITP viral infections (e.g., EBV) congenital bone marrow disorders
Macrocytosis	Enlarged red blood cells	Vitamin B12 deficiency folate deficiency liver disease hypothyroidism alcoholism
Hematological Abnormalities in Infectious Diseases	Blood count changes due to infections	EBV: Atypical lymphocytosis HIV: CD4+ T cell depletion, pancytopenia

Causes of Neutropenia and Leukopenia

Condition	Description	Potential Causes
Neutropenia	Low neutrophil count	Infections (HIV, hepatitis, influenza) severe bacterial infections chemotherapy certain antibiotics antithyroid drugs aplastic anemia myelodysplastic syndromes leukemias autoimmune neutropenia SLE, rheumatoid arthritis vitamin B12 or folate deficiency hypersplenism
Lymphopenia	Low lymphocyte count	Infections: Viral infections (e.g., HIV, hepatitis, influenza, COVID-19), severe bacterial infections, sepsis Medications: Chemotherapy, immunosuppressants, corticosteroids Autoimmune Disorders: Systemic lupus erythematosus (SLE), rheumatoid arthritis Nutritional Deficiencies: Severe malnutrition, zinc deficiency Bone Marrow Disorders: Aplastic anemia, myelodysplastic syndromes, leukemias Other: Radiation therapy, congenital immunodeficiency disorders (e.g., DiGeorge syndrome), stress, uremia

Multiple Myeloma, Leukemia, and Lymphoma

Condition	Blood Test Findings	Other Investigations
Multiple Myeloma	Anemia rouleaux formation on peripheral smear elevated ESR hypercalcemia increased total protein with reversal of albumin/globulin ratio, elevated serum creatinine	Serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), immunofixation electrophoresis, bone marrow biopsy, skeletal survey (X-rays)
Leukemia	Varies by type:	Bone marrow biopsy, cytogenetic analysis, flow cytometry, molecular testing (e.g., PCR for specific genetic abnormalities)
	– Acute lymphoblastic leukemia (ALL):	Anemia thrombocytopenia leukocytosis or leukopenia blasts on peripheral smear
	– Acute myeloid leukemia (AML):	Anemia thrombocytopenia leukocytosis or leukopenia myeloblasts on peripheral smear
	– Chronic lymphocytic leukemia (CLL):	Lymphocytosis smudge cells on peripheral smear
	– Chronic myeloid leukemia (CML):	Leukocytosis with a left shift basophilia eosinophilia
Lymphoma	Varies by type:	Lymph node biopsy, imaging studies (CT, PET scan), bone marrow biopsy for staging
	– Hodgkin lymphoma: Possible anemia, eosinophilia, elevated ESR
	– Non-Hodgkin lymphoma: Varies widely depending on subtype; may include anemia, leukocytosis, lymphocytosis, or other abnormalities

This table summarizes the hematological abnormalities, their de

• Obtain a detailed history and perform a focused clinical examination of different types of anaemia:
  • iron deficiency and other hypoproliferative anaemias, as occur in acute and chronic inflammation, chronic kidney disease
  • inherited haemoglobinopathies, such as thalassaemia
  • megaloblastic anaemias, such as B12 and folate deficiencies
  • haemolytic anaemias caused by common drugs, such as cephalosporins and non-steroidal anti-inflammatories
  • blood loss due to gastrointestinal disorders, such as angiodysplasias
  • blood loss related to menstrual disorders.
• Generate differential diagnoses for anaemia in a child by gathering information through a focused history and examination, which might include:
  • nutritional deficiencies, such as iron, B12 and folate deficiency
  • parasitic infections, such as hookworm infestation
  • inherited haemoglobinopathies, such as thalassaemia and sickle cell disease
  • G6PD deficiency.

Nutritional Deficiencies (Iron, B12, Folate)

• Key Features on History:
  • Fatigue, pallor, weakness, irritability
  • Poor appetite
  • Developmental delay or cognitive difficulties
  • Pica (eating non-food items)
  • Glossitis, cheilitis (in B12 deficiency)
  • Neurological symptoms (e.g., numbness, tingling, difficulty walking in B12 deficiency)
• Risk Factors:
  • Poor dietary intake
  • Vegetarian or vegan diet (B12 deficiency)
  • Chronic malabsorption syndromes (e.g., celiac disease)
  • Low socioeconomic status
  • Premature birth or low birth weight
  • Exclusive breastfeeding without iron supplementation beyond 6 months

Parasitic Infections (e.g., Hookworm Infestation)

• Key Features on History:
  • Fatigue, pallor, weakness
  • Abdominal pain, diarrhea
  • Weight loss
  • History of living in or traveling to endemic areas
• Risk Factors:
  • Living in or traveling to areas with poor sanitation
  • Walking barefoot in contaminated soil
  • Poor hygiene practices
  • Lack of access to deworming medications

Inherited Hemoglobinopathies (e.g., Thalassemia, Sickle Cell Disease)

• Key Features on History:
  • Family history of similar conditions
  • Chronic fatigue, pallor
  • Episodes of pain (sickle cell disease)
  • Jaundice, dark urine
  • Growth retardation
  • Bone deformities (thalassemia major)
• Risk Factors:
  • Family history of hemoglobinopathies
  • Ethnic background (Mediterranean, African, Southeast Asian for thalassemia; African, Hispanic, Middle Eastern for sickle cell)
  • Known carrier status

G6PD Deficiency

• Key Features on History:
  • Episodes of jaundice, dark urine
  • Fatigue, pallor, weakness
  • History of hemolytic episodes triggered by certain foods (fava beans), medications, or infections
• Risk Factors:
  • Family history of G6PD deficiency
  • Male gender (X-linked inheritance)
  • Ethnic background (African, Mediterranean, Asian)
  • Exposure to known triggers

• Evaluate a patient with recurrent fever who may have an undiagnosed malignancy, such as acute leukaemia.

Recurrent Fever with Potential Malignancy (e.g., Acute Leukemia)

• Key Features:
  • Recurrent fever
  • Fatigue, pallor, weakness
  • Easy bruising, bleeding
  • Bone pain
• Symptoms:
  • Persistent infections
  • Weight loss, night sweats
• Signs:
  • Pallor
  • Petechiae, purpura
  • Hepatosplenomegaly
  • Lymphadenopathy
• Diagnosis:
  • Complete blood count (CBC) with differential: anemia, leukocytosis or leukopenia, thrombocytopenia, presence of blasts
  • Bone marrow biopsy: >20% blasts in bone marrow
  • Flow cytometry: to identify specific leukemia markers
  • Cytogenetic and molecular studies
• Management:
  • Immediate referral to hematology/oncology
  • Chemotherapy
  • Supportive care: transfusions, antibiotics for infections
  • Consideration of bone marrow transplant

• Evaluate and manage a patient with lymphadenopathy, with or without splenomegaly.

Lymphadenopathy Evaluation and Management

• Key Features:
  • Enlarged lymph nodes
  • Fever, night sweats, weight loss (B symptoms)
• Symptoms:
  • Painful or painless lymph nodes
  • Systemic symptoms (if malignancy suspected)
• Signs:
  • Firm, rubbery, or hard lymph nodes
  • Splenomegaly
• Diagnosis:
  • CBC with differential
  • Lymph node biopsy (excisional preferred)
  • Imaging: Ultrasound, CT, PET scan
  • Serological tests for infections (e.g., EBV, CMV, HIV)
• Management:
  • Treat underlying infection if present
  • Referral to hematology/oncology if malignancy suspected
  • Observation for benign causes
  • Chemotherapy, radiation therapy for confirmed lymphoma

• Evaluate and manage a patient with polycythaemia.

Polycythemia Evaluation and Management

• Key Features:
  • Headache, dizziness
  • Pruritus, especially after hot shower
  • Redness of skin, especially face (plethora)
• Symptoms:
  • Fatigue, weakness
  • Visual disturbances
• Signs:
  • Hypertension
  • Splenomegaly
• Diagnosis:
  • CBC: elevated hemoglobin/hematocrit
  • Erythropoietin (EPO) level
  • JAK2 mutation analysis
  • Bone marrow biopsy
• Management:
  • Phlebotomy to reduce hematocrit
  • Low-dose aspirin
  • Cytoreductive therapy (e.g., hydroxyurea) in high-risk patients
  • Manage underlying causes (e.g., cessation of smoking)

• Evaluate and manage idiopathic thrombocytopenic purpura (ITP) in children and adults.

4. Idiopathic Thrombocytopenic Purpura (ITP)

• Key Features:
  • Easy bruising, petechiae, purpura
  • Mucosal bleeding (e.g., nosebleeds, gum bleeding)
• Symptoms:
  • Fatigue
  • Asymptomatic (in some cases)
• Signs:
  • Low platelet count on CBC
  • Normal bone marrow examination (megakaryocytes present)
• Diagnosis:
  • Exclusion of other causes of thrombocytopenia
  • CBC with peripheral smear
  • Bone marrow biopsy (if indicated)
• Management:
  • Children: Observation (if mild), corticosteroids, IVIG
  • Adults: Corticosteroids, IVIG, thrombopoietin receptor agonists
  • Splenectomy in refractory cases
  • Platelet transfusions (if severe bleeding)

• Investigate a patient presenting with polycythaemia for primary causes, such as polycythaemia rubra or secondary to conditions, such as smoking or exogenous testosterone administration.

Polycythemia Causes Investigation

• Key Features:
  • Primary: Polycythemia rubra vera (JAK2 mutation)
  • Secondary: Chronic hypoxia (smoking, COPD), exogenous testosterone, high-altitude living
• Diagnosis:
  • CBC: elevated hemoglobin/hematocrit
  • Erythropoietin (EPO) level: low in primary, high in secondary
  • JAK2 mutation analysis
  • Oxygen saturation, carboxyhemoglobin levels
• Management:
  • Phlebotomy
  • Address underlying causes (e.g., smoking cessation, treating COPD)
  • Low-dose aspirin
  • Cytoreductive therapy for high-risk patients

• Investigate an individual who presents with abnormal blood counts for asymptomatic myeloproliferative disorders, such as chronic leukaemias and lymphomas.

Abnormal Blood Counts and Myeloproliferative Disorders

• Key Features:
  • Chronic leukemias: Fatigue, weight loss, splenomegaly
  • Myeloproliferative disorders: Polycythemia, thrombocytosis, leukocytosis
• Diagnosis:
  • CBC with differential
  • Peripheral blood smear
  • Bone marrow biopsy
  • Cytogenetic and molecular studies (e.g., BCR-ABL for CML)
• Management:
  • Referral to hematology
  • Targeted therapies (e.g., tyrosine kinase inhibitors for CML)
  • Supportive care
  • Regular monitoring and follow-up

• Identify, evaluate and manage a patient with haemochromatosis, including performing a venesection.
• Manage a patient with iron deficiency refractory to oral iron therapy with iron infusion.
• Identify, evaluate and manage plasma cell disorders in an asymptomatic adult who presents with an elevated ESR and raised serum protein and globulin during a routine blood investigation:
  • multiple myeloma
  • monoclonal gammopathy of undetermined significance (MGUS).
• Identify common haematological presentations in high-risk populations, including:
  • anaemia in Aboriginal and Torres Strait Islander peoples
  • haemoglobinopathies in certain immigrant populations; for example, individuals from South-East Asian, Middle Eastern and Mediterranean regions
  • nutritional deficiency-related anaemias in refugee populations
  • pregnancy

Summary Table

Population	Common Hematological Presentations	Key Features	Why
Aboriginal and Torres Strait Islander Peoples	Iron deficiency anemia, anemia of chronic disease	Fatigue, pallor, weakness, poor appetite, frequent infections	Nutritional factors, infectious diseases, chronic diseases, socioeconomic factors
Certain Immigrant Populations (South-East Asian, Middle Eastern, Mediterranean)	Thalassemia, Sickle Cell Disease	Microcytic anemia, splenomegaly, bone deformities, vaso-occlusive crises, jaundice	Genetic predisposition, migration patterns
Refugee Populations	Iron deficiency anemia, vitamin B12 and folate deficiency anemia	Fatigue, pallor, pica, developmental delays, neurological symptoms	Poor nutritional intake, chronic infections, parasitic infestations, socioeconomic factors
Pregnancy	Physiological anemia, iron deficiency anemia, folate deficiency anemia	Fatigue, pallor, dizziness, pica, neural tube defects	Increased nutritional demands, blood volume expansion, poor dietary intake

• Generate an immunisation plan for an individual presenting with functional asplenia or splenectomy.

Individuals with functional asplenia or splenectomy are at increased risk for infections, particularly from encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), and Neisseria meningitidis. An appropriate immunisation plan is crucial to prevent these infections.

1. Pre-Splenectomy (if planned)

• Vaccinate at least 2 weeks before elective splenectomy whenever possible.

2. Post-Splenectomy (if unplanned)

• Vaccinate as soon as the patient is stable, ideally within 2 weeks post-splenectomy.

Immunisation Schedule

Pneumococcal Vaccines

1. 13-valent pneumococcal conjugate vaccine (PCV13)
   • Dose: Single dose if not previously vaccinated
   • Timing: At least 2 weeks before splenectomy or as soon as possible post-splenectomy
2. 23-valent pneumococcal polysaccharide vaccine (PPSV23)
   • Dose: Single dose at least 8 weeks after PCV13
   • Booster: One-time revaccination with PPSV23 after 5 years

Meningococcal Vaccines

1. Meningococcal conjugate vaccine (MenACWY)
   • Dose: Two doses of MenACWY at least 8 weeks apart if not previously vaccinated
   • Booster: Every 5 years
2. Serogroup B meningococcal vaccine (MenB)
   • Dose: Two or three doses depending on the specific vaccine used
   • Timing: As per the manufacturer’s schedule

Haemophilus Influenzae Type B (Hib) Vaccine

• Dose: Single dose if not previously vaccinated
• Timing: At least 2 weeks before splenectomy or as soon as possible post-splenectomy

Influenza Vaccine

• Dose: Annually
• Type: Inactivated influenza vaccine (IIV)

Other Vaccines

1. Tetanus, Diphtheria, Pertussis (Tdap) Vaccine
   • Dose: One dose of Tdap if not previously received, followed by Td every 10 years
2. Hepatitis B Vaccine
   • Dose: Three doses if not previously vaccinated
   • Timing: 0, 1, and 6 months schedule
3. Human Papillomavirus (HPV) Vaccine
   • Dose: As per age-appropriate schedule
4. Measles, Mumps, Rubella (MMR) Vaccine
   • Dose: If not previously vaccinated and no evidence of immunity
5. Varicella Vaccine
   • Dose: If not previously vaccinated and no evidence of immunity

• Manage a patient presenting with an episode of unprovoked thrombosis such as deep vein thrombosis and investigate appropriately where the cause is unclear.

Management and Investigation of Unprovoked Thrombosis (e.g., Deep Vein Thrombosis)

Initial Management

1. Clinical Assessment
   • History: Assess for risk factors, previous thrombotic events, family history, recent immobilization, surgery, or hormonal therapy.
   • Symptoms: Pain, swelling, redness, and warmth in the affected limb.
   • Physical Examination: Measure limb circumference, assess for signs of DVT (e.g., Homan’s sign, although not highly specific).
2. Immediate Treatment
   • Anticoagulation: Initiate anticoagulant therapy to prevent thrombus extension and reduce the risk of pulmonary embolism (PE).
     • First-line Options:
       • Low molecular weight heparin (LMWH) (e.g., enoxaparin)
       • Direct oral anticoagulants (DOACs) (e.g., rivaroxaban, apixaban)
       • Unfractionated heparin (for patients with severe renal impairment)
     • Long-term Options:
       • Warfarin (with overlap of LMWH until therapeutic INR achieved)
       • Continuation of DOACs
3. Hospital Admission Criteria
   • Massive DVT (e.g., phlegmasia cerulea dolens)
   • PE suspicion
   • Severe symptoms
   • Comorbidities requiring inpatient care

Diagnostic Investigations

1. Initial Laboratory Tests
   • Complete Blood Count (CBC): Assess for anemia, leukocytosis, or thrombocytopenia.
   • Coagulation Profile: PT, aPTT, INR to evaluate baseline coagulation status.
   • Renal and Liver Function Tests: Ensure safe use of anticoagulants.
   • D-Dimer: Elevated in the presence of thrombosis, but non-specific.
2. Imaging Studies
   • Compression Ultrasound: First-line imaging for DVT diagnosis.
   • Venography: Consider if ultrasound is inconclusive or if more detailed imaging is required.
   • CT Pulmonary Angiography (CTPA): If PE is suspected.
3. Further Investigations for Underlying Causes
   • Thrombophilia Screening: After initial anticoagulation phase (typically 3-6 months) or in patients with strong family history or recurrent unprovoked thrombosis.
     • Factor V Leiden mutation
     • Prothrombin gene mutation
     • Protein C, Protein S, and Antithrombin deficiencies
     • Lupus anticoagulant and anticardiolipin antibodies (for antiphospholipid syndrome)
   • Malignancy Screening: Particularly in patients over 50 or with recurrent unprovoked thrombosis.
     • History and physical examination
     • Age-appropriate cancer screening (e.g., mammography, colonoscopy)
     • CT scans (if clinically indicated)
4. Additional Considerations
   • Hormonal Assessments: In women, assess for use of oral contraceptives or hormone replacement therapy.
   • Family History: Investigate for hereditary thrombophilia.

Ongoing Management

1. Anticoagulation Duration
   • First Episode of Unprovoked DVT: At least 3-6 months of anticoagulation.
   • Extended Therapy: Consider if there is a high risk of recurrence or ongoing risk factors.
2. Monitoring and Follow-up
   • Regular monitoring of INR for patients on warfarin.
   • Periodic follow-up visits to assess for compliance, side effects, and risk of recurrence.
   • Reassessment of the need for continued anticoagulation beyond initial treatment period.
3. Lifestyle Modifications
   • Encourage smoking cessation, weight management, and regular physical activity.
   • Educate about signs of recurrence and when to seek medical help.
4. Compression Stockings
   • Consider for patients with persistent symptoms or to prevent post-thrombotic syndrome.
5. Patient Education
   • Importance of medication adherence.
   • Awareness of signs and symptoms of DVT and PE.
   • Risks and benefits of anticoagulation therapy.

Summary

Immediate management involves anticoagulation therapy, clinical assessment, and appropriate diagnostic imaging. Long-term management includes evaluating for underlying causes, ongoing anticoagulation, lifestyle modifications, and patient education. Regular follow-up is crucial to monitor treatment efficacy, compliance, and recurrence prevention.

• Prepare a list of common drug interactions from a haematological perspective; for example, warfarin with paracetamol.

Summary Table

Drug	Interacting Drug	Effect	Mechanism	Recommendation
Warfarin	Paracetamol	Increased anticoagulant effect	Enhanced anticoagulant effect	Monitor INR; avoid high doses
Warfarin	NSAIDs	Increased risk of GI bleeding	Inhibited platelet function, GI irritation	Avoid or monitor closely
Warfarin	Antibiotics (Ciprofloxacin, Metronidazole)	Increased anticoagulant effect	Altered gut flora, inhibited metabolism	Monitor INR more frequently
Warfarin	Amiodarone	Increased anticoagulant effect	Inhibited warfarin metabolism	Reduce dose, monitor INR
Heparin	Antiplatelet Agents (Aspirin, Clopidogrel)	Increased risk of bleeding	Combined antiplatelet and anticoagulant effects	Use with caution, monitor
Heparin	Thrombolytics (Alteplase)	Increased risk of bleeding	Additive effects on clot breakdown	Strict monitoring
DOACs	Antifungals (Ketoconazole)	Increased anticoagulant effect	Inhibited DOAC metabolism	Avoid combination, reduce dose
DOACs	Anticonvulsants (Carbamazepine)	Decreased anticoagulant effect	Induced DOAC metabolism	Monitor effect, adjust dose
Aspirin	Other NSAIDs (Ibuprofen)	Increased risk of GI bleeding	Additive GI irritation and platelet inhibition	Avoid combination, use gastroprotective agents
Aspirin	SSRIs/SNRIs (Fluoxetine, Venlafaxine)	Increased risk of bleeding	Inhibited platelet function	Monitor for bleeding
Clopidogrel	PPIs (Omeprazole)	Reduced antiplatelet effect	Inhibited activation of clopidogrel	Use alternative PPIs
Clopidogrel	Warfarin	Increased risk of bleeding	Additive anticoagulant effects	Monitor INR and bleeding
Methotrexate	NSAIDs	Increased toxicity	Reduced renal clearance of methotrexate	Avoid combination, monitor
Methotrexate	Trimethoprim-Sulfamethoxazole	Increased risk of bone marrow suppression	Additive effects on folate metabolism	Monitor blood counts closely
Corticosteroids	Warfarin	Variable effect on INR	Altered warfarin metabolism	Monitor INR closely
Corticosteroids	Antidiabetic Agents (Insulin, Metformin)	Hyperglycemia	Increased blood glucose levels	Monitor blood glucose, adjust medication

Evaluate and manage a patient receiving chemotherapy and presenting with febrile neutropenia.

Evaluation and Management of a Patient with Febrile Neutropenia

Febrile neutropenia is a medical emergency in patients receiving chemotherapy. It is characterized by a fever in a patient with an abnormally low number of neutrophils, which places them at high risk for serious infections.

Evaluation

1. Initial Assessment
   • History: Obtain detailed history including chemotherapy regimen, timing of last chemotherapy dose, symptoms of infection, recent hospitalizations, and current medications.
   • Symptoms: Fever (≥38.3°C or ≥38.0°C sustained over 1 hour), chills, malaise, signs of localized infection (e.g., cough, sore throat, dysuria).
   • Physical Examination: Thorough examination to identify possible sources of infection (skin, oral cavity, lungs, abdomen, perineum).
2. Laboratory Investigations
   • Complete Blood Count (CBC): Confirm neutropenia (absolute neutrophil count [ANC] < 500 cells/µL or expected to decrease below 500 cells/µL within 48 hours).
   • Blood Cultures: Obtain at least two sets of blood cultures (from different sites, including central line if present).
   • Other Cultures: Urine culture, sputum culture, and cultures from any suspected sites of infection.
   • Basic Metabolic Panel: Assess renal function and electrolytes.
   • Liver Function Tests: Check for hepatic involvement or drug toxicity.
   • Lactate Level: Evaluate for sepsis.
   • Chest X-Ray: If respiratory symptoms are present or there is no obvious source of infection.

Initial Management

1. Empirical Antibiotic Therapy
   • Prompt Initiation: Start broad-spectrum intravenous antibiotics within 1 hour of presentation.
   • Antibiotic Choices: Choose based on local antibiogram and patient-specific factors. Common regimens include:
     • Monotherapy: Piperacillin-tazobactam, cefepime, meropenem, or imipenem-cilastatin.
     • Combination Therapy: If high-risk for multidrug-resistant organisms, consider adding vancomycin for gram-positive coverage or an aminoglycoside for gram-negative coverage.
2. Supportive Care
   • Fluids: Intravenous fluids to maintain hemodynamic stability.
   • Antipyretics: Acetaminophen for fever management (avoid NSAIDs due to potential renal and gastrointestinal side effects).

Risk Stratification

1. High-Risk Patients:
   • Profound neutropenia (ANC < 100 cells/µL) expected to last >7 days.
   • Significant comorbidities (e.g., hypotension, pneumonia, new-onset abdominal pain, altered mental status).
   • Hospitalization required for intravenous antibiotics and supportive care.
2. Low-Risk Patients:
   • Brief duration of neutropenia (<7 days).
   • Stable and no significant comorbidities.
   • Consider outpatient management with oral antibiotics (e.g., ciprofloxacin plus amoxicillin-clavulanate) after initial intravenous antibiotics and clinical stability is confirmed.

Further Management and Monitoring

1. Ongoing Monitoring:
   • Vital Signs: Regular monitoring for signs of clinical deterioration.
   • Laboratory Tests: Daily CBC and blood cultures as needed.
   • Re-evaluation: Regular reassessment for clinical response to antibiotics.
2. Modification of Therapy:
   • Clinical Deterioration or Lack of Improvement: Re-evaluate for resistant organisms, secondary infections, or alternative diagnoses.
   • Antibiotic Adjustment: Based on culture results and sensitivity data.
3. Duration of Therapy:
   • Clinically Documented Infection: Continue antibiotics until infection is resolved and ANC > 500 cells/µL.
   • Unexplained Fever: Continue antibiotics until ANC > 500 cells/µL and patient has been afebrile for at least 48 hours.
4. Antifungal Therapy:
   • Consider in patients who remain febrile after 4-7 days of broad-spectrum antibiotics, especially if high-risk for fungal infections.
5. Granulocyte Colony-Stimulating Factor (G-CSF):
   • May be considered to reduce the duration of neutropenia, particularly in high-risk patients or those with complications.

Patient Education and Follow-Up

• Education: Inform the patient and caregivers about the signs and symptoms of infection, the importance of early reporting, and adherence to prescribed therapy.
• Follow-Up: Close follow-up with oncologist and primary care provider to monitor for complications and adjust treatment as needed.