PERDANA UNIVERSITY RCSI

CASE BASED LEARNING

CASE NO: 6
Monday 7th April 2014 - Thursday 10st April 2014

Clinical Discussants
Microbiologist:
Pathology:
Moderator:

Dr. Sufi Hannan

Prof Shiran
Prof Anthony Cunningham

Presenting Complaint
Feeling cold and shivery on Day 11 following a first cycle of
chemotherapy

History of Present Illness

The patient, CL, was an 26-year-old Malay man who was diagnosed with
acute myelogenous leukaemia 3 weeks previously. He was
commenced on the first cycle of Remission Induction chemotherapy
11 days prior to the current presenting complaint. He tolerated the
chemotherapy well. On Day 7 (the final day of the first Remission
Induction cycle), he was found to be neutropenic (White cell count
1.5 x109/l (4.0-11.0 x109/L), neutrophil count 0.7 x109/l (2.0-7.5
x109/L).
Now on Day 11 following the chemotherapy, he is complaining of feeling
cold and shivery. Further questioning reveals that he feels tired, weak
and unwell, he has no appetite and feels nauseated.

Past Medical and Surgical History

Appendicectomy at age 7 years, no other medical or surgical history

Family History

 His father, aged 58 years, has hypertension and Type 2 Diabetes

Mellitus. His mother, aged 52 years, suffers from recurrent urinary
tract infection but is otherwise well and on no medications.
Three siblings are alive and well with no medical complaints

Social History
CL works in a Bank. Prior to this hospital admission, he smoked 15
cigarettes a day. He does not drink alcohol or use recreational drugs.
He is a keen keep fit follower, and normally goes to the gym 4 times
a week.

Medications
Aciclovir
Fluconazole
Anti-nausea mediations

Allergies
No known drug allergies

Review of Systems
He is alert, and orientated in time and place.
He has no cough, shortness of breath or chest pain. He has no dysuria. He
has no diarrhoea.

Physical Examination
Vital Signs:
Temperature: 38.8oC,
Heart rate: 118 beats per minute
Blood Pressure: 110/50
Respiratory Rate: 32 breaths per minute
General Inspection
Flushed, no evidence of rash, Hickman line site dry and clean
Cardiovascular System, Respiratory System and Abdominal
Examination: No abnormality detected:

Investigations
Bloods are taken for full blood count and differential,
Chest X ray was performed
Two sets of blood cultures are taken, one set from the from the
central line and one set from the right forearm.
A swab was taken from the Hickman site
Working Diagnosis and Management
A diagnosis of probable neutropenic sepsis was made, and treatment was
commenced with intravenous piperacillin-tazobactam.

Results of Laboratory Investigations

White cell count 0.7 x 109/L, neutrophils 0.2 x 109/L

Urinalysis: no abnormality detected on dipstick, white cell count 1/cmm,
sterile on culture after 18 hours incubation
Blood cultures sterile after 18 hours incubation

Radiology
PA chest x-ray (Image 1):

Image 1
Clinical Course
24 hours after the initial complaint, CL complained of feeling very unwell
and had a temperature spike to 39.5oC. Blood pressure was 95/50mmHg,
his heart rate was 124 beats per minute. Physical examination was
unremarkable.
Because of his clinical deterioration, the septic screen was repeated
(Central line, and peripheral blood cultures, Urine, and chest X ray).
Gentamicin 5 mg/Kg once daily iv was added to the antibiotic regimen.
CL continued to spike a pyrexia. Six hours later he complained of pain at
the Hickman line insertion site. On examination, there was erythema
around the site with and scanty discharge from the site.
A phoned report was received from the Clinical Microbiology Laboratory:
Gram positive cocci seen on Gram stain from blood culture bottle (central
line cultures) (Image 2)

Image 2: Gram stain of

aliquot from blood culture
bottle

Treatment with piperacillin-tazobactam plus gentamicin was continued,

and intravenous vancomycin was added to the regimen.
Within 48 hours of the initial blood cultures, the laboratory confirmed that
the blood culture isolate was Staphylococcus epidermidis, susceptible to
vancomycin; the peripheral line cultures remained sterile.
The central and peripheral line blood cultures were repeated on that day
and each of the following 3 days.
Cl showed clinical improvement; his blood pressure returned to normal
and the pyrexia settled but remained elevated between 37.80C and
380C. He continued to complain of pain at the Hickman line exit site and
the erythema became more extensive. The central line blood cultures
continued to remain culture positive for Staphylococcus epidermidis. The
Hickman line was removed and the tip was sent for culture and sensitivity
and a new line was inserted at another site. Central and peripheral blood
cultures were repeated 24 hours after removal of the infected line.
Within 18 hours of line removal, his temperature had returned to normal
and CL felt well.
The repeat blood cultures were sterile.
On Day 24 after commencement of the first treatment cycle, CLs white
cell ount had not recovered, and he continued to be neutropenic with a
neutrophil count of 0.7 x 109/L. On Day 26, he complained of dry cough
and shortness of breath.
Chest X Ray (Image 3) was performed followed by CT Thorax (Image 4)

Image 3

Image 4

Broncho-alveolar lavage was performed and the specimen was sent for
culture and sensitivity; a lung biopsy specimen was sent for histology. An
organism was isolated after 3 days incubation on Sabouraud dextrose
agar (Image 5) . Microscopy was performed (Image 6).

Image 5

Image 6

Histology of the lung biopsy (Image 7)

Image 7

Treatment was commenced with an appropriate agent. CL responded well

to treatment, and became asymptomatic after 3 weeks treatment.
Treatment continued for a total of 5 weeks. During this time, the cough

and shortness of breath resolved and the chest X ray appearance returned
to normal.
His white cell count continued to improve during this time, and returned to
normal following completion of this treatment. The second Remission
Induction cycle of chemotherapy was administered without any infective
complications.

Questions
Student 1
What is the definition of neutropenia?
What are the causes of neutropenia?
Explain why neutropenic patients are at increased risk of infection.

Student 2
What infections may be encountered in neutropenic patients?
What measures would be appropriate to reduce the risk of
development of opportunistic infection in CL?
Interpret and compare Images 1 and 3.

Student 3
What abnormality is seen on the CT scan?
What is the differential diagnosis?
What investigations would be appropriate to confirm a diagnosis in
this setting?

Student 4

Describe what is seen in Images 5, 6 and 7.

What is the diagnosis?
What are the possible complications of this condition?
What is the most appropriate treatment

Student 5
Describe the different types of single room isolation
What sort of isolation is appropriate for a patient with AML?
What precautions would you take on entering the room and how do
these precautions differ from those that you would take on entering
the room of a patient with MRSA infection, or a patient with open
pulmonary tuberculosis

Student 6
What is a Hickman line?
What are the advantages of this type of line in comparison with a
peripheral line?
What measures are recommended to reduce the risks of infection in
association with this type of iv access line?