Neutropenia is a blood disorder that can affect anyone. Some people are born with it.

It can happen after a viral infection. In some

cases the cause can be a side effect of a drug, or exposure to certain

poisons. People can get neutropenia when treated for cancer with chemotherapy drugs. Sometimes it happens for no known reason.

Blood is made up of billions of cells. There are many different types of

blood cells, but most of the time you hear about two kinds - red cells and white cells. There are more red cells than any other type of blood

cell. They are very important as they carry oxygen from your lungs to all
parts of your body. White blood cells are just as important, but for a very different reason. One of their jobs is to protect you from infection.

There are several kinds of white cells. Each has a special function. The most common ones are: Neutrophils (pronounced NEW TROH FILS), which surround and destroy bacteria in your body; and

Lymphocytes (pronounced LIM FOH SITES), which are the key part of your bodys immune system, and defend against viruses.
A third kind of blood cell, the platelet, helps your blood to clot.
Normal neutrophil function depends on the integration of chemotaxis, phagocytosis,
degranulation and oxidative metabolism. As congenital and acquired neutrophil abnormalities increase the risk of infection, frequently with no other diagnostic features, diagnosis depends upon specialist laboratory investigations. Techniques for quantitative

evaluation of the principal neutrophil functions are discussed, and a preliminary

screening programme for neutrophil abnormalities proposed.

What is neutrophil?
is a type of white blood cell in the granulocytic series, formed by myelopoietic tissue of the bone marrow (sometimes also in extramedullary sites), and released into the circulating blood, where they normally represent 5465% of the total number of leukocytes.

-A

type of white blood cell (WBC) filled with microscopic sacs (granules) containing

enzymes that digest bacteria and other microorganisms. This process is known as phagocytosis.

-Neutrophils

respond to infection and attack bacteria and other foreign invaders

directly.
- Any cell or tissue that manifests no special affinity for acid or basic dyes, the cytoplasm stains approximately equally with either type of dye.

Neutrophils are the first type of immune cell to respond to and arrive at
the site of infection, often within an hour. They will respond to infection inside the body, but also on the surface, as in the case of skin infections.

Pus, which is one visible sign of a skin infection, contains mainly dead neutrophils, bacteria, and cells. Pus can form internally, as well.

The results of a common blood test, called an absolute neutrophil count (ANC), are routinely checked during cancer treatment to determine how

the immune system is responding to treatment. When ANC is low, this is

called neutropenia..

If ANC drops below about 500 cells per microliter, the risk of

infection increases and your doctor may prescribe medications to bring

ANC back into a normal range and temporarily offer antibiotics to prevent serious infections. Neutrophils are part of the innate immune system, which means that they can "non-specifically" destroy any invaders that they encounter in the body, such as bacteria and parasites. Non-specifically means that neutrophils do not have to recognize the invader specifically, but instead simply recognize the invader as something that should not be present in the body and should be destroyed.

-is a blood disorder where the body has an excessively low number of
one type of white blood cells known as neutrophil granulocytes, or neutrophils,. Around 50 to 70% of the white blood cells circulating around the body are made up of neutrophils. These white blood cells are responsible for attacking and eliminating

any bacteria that invade the body, and they function as the first line of
defense against infections. People who have Neutopenia are more vulnerable to bacterial infections, and if these infections are not treated

immediately, they can cause Neutropenic Sepsis, which is considered

serious and life-threatening.

:
-bone marrow has a problem producing neutrophils in cases of cancer -Vitamin B12 or folic acid deficiency, -hereditary disorders like Congenital Neutropenia -exposure to pesticides -undergoing radiation therapy. -white blood cell destruction like aplastic anemia, Autoimmune Neutropenia, chemotherapy and hemodialysis treatments. -contracts a viral infection. (mild case)

The measurement of how severe a Neutropenia case is will

depend on a person's neutrophil count. Normal neutrophil

levels in adults fall between 1,500 to 7,000 neutrophils per mm3. Children under 7 years of age may have a lower neutrophil count.

Patients with mild Neutropenia will have an absolute

neutrophil count (ANC) of below 1,500 per mm3, moderate cases have an ANC of between 500 to 1,000 per mm3, while the ANC of severe Neutropenia falls below the 500 per mm3 level.

Females have a higher risk for Neutropenia, as are elderly adults. A person with severe Neutopenia will need immediate medical attention, as there is a greater potential for

several types of infection to develop, such as

bacterial, fungal or viral, or all three at once

combined.

-can

develop symptoms over the course of a few days or even

hours.

- sufferers can develop the disease gradually, but are affected for
months, and even years. Chronic Neutropenia will often exhibit no symptoms until an infection sets in.

ofever

mouth ulcers o anal sores o ear and gum infections o tonsilitis o sore throats o skin abscesses o periodontal disease
o

diarrhea o swelling
o
In some cases, life-threatening infections or sepsis can set in, requiring hospitalization and intravenous administration of antibiotics. These infections usually manifest themselves in the mouth, throat, sinuses, lungs, and skin.

Is the development of fever, often with other signs of infection, in a patient with neutropenia, an abnormally low number of neutrophil

granulocytes (a type of white blood cell) in the blood.

Mouth ulcers are sores or open lesions in the mouth.

To diagnose Neutropenia, the doctor may order a complete blood count to determine the number of neutrophils in the blood. Sometimes, to make a precise diagnosis especially if the doctor suspects other serious illnesses, a bone marrow aspiration or biopsy may be necessary. In a bone marrow biopsy, the doctor will use a needle to take a sample of the patient's bone marrow and examine it under a microscope. The doctor will be looking for impaired neutrophil production, or if there has been excessive use or destruction of these cells. This test will show if there are any signs of an intrinsic defect in the marrow, Congenital Neutropenia, maturation arrest, a fungal infection, a lack of Vitamin B12 or a folate deficiency in the body. There may be other diseases present, as well, like leukemia, tuberculosis, and other cancers.

When the patient exhibits a form of Neutropenic fever, laboratory tests like blood cultures, urinalysis, Sputum Gram stain and culture, and measuring the serum Vitamin B12 and RBC folate levels may be recommended.

For patients already afflicted with an infection, taking radiograph

images of the posterio-anterior and lateral chests may be required to check for any signs of pneumonia.

o o

round of antibiotics sargramostin (Leukine, Prokin), a blood growth factor that acts to stimulate the

production of white blood cells.(Patients who have acquired Neutropenia through

chemotherapy for cancer treatments)

o

B-complex vitamins and folic acid supplements,(For patients who have acquired spleen removal for patients who incur repeat infections because of Felty's syndrome

Neutropenia due to a nutritional deficiency or a poor diet)

o

stool softeners to remedy constipation

ointments and creams for infected wounds and abrasions;

omedicated o o

colony-stimulating growth factors to induce white blood cell production corticosteroid treatment for Neutropenia caused by an autoimmune reaction globulin to treat symptoms of aplastic anemia,

oAntithymocyte o

bone marrow or stem cell transplant to treat more severe cases of Neutropenia like

leukemia or aplastic anemia.

People diagnosed with Neutropenia should avoid getting an infection by observing proper hygiene, keeping clean surroundings, and

avoiding crowded public places where they may be exposed to a

whole range of germs, viruses and bacteria. They should also avoid exposing themselves to other people who are sick to prevent any contamination. Other ways of preventing infection while neutropenic include wearing sunscreen, taking proper care of teeth and gums, avoiding contact sports which may cause cuts or injuries, avoiding the use of rectal suppositories, tampons, and even sexual intercourse.

There is an excellent prognosis for Neutropenia. Patients' recovery will depend on how severe the complications are. Usually, only 21% of patients incur serious complications, and recovery is even faster if the disease is diagnosed and treated immediately. In cancer

patients suffering from Neutropenia due to chemotherapy treatments, the mortality rate
is 4 to 30%. Scientists at the Northwest Hepatitis C Resource Center working on Neutropenia Prevention have recently found that using an alternative treatment combination of ribavirin, pegylated interferon, erthropoietin and ganulocyte colony-stimulating factor can control anemia and Neutropenia during anti-hepatitis C therapy. The use of acupuncture is another alternative therapy undertaken by the NESA

Acupuncture Research Collaborative to reduce Neutropenia brought about by

chemotherapy treatments in women diagnosed with gynecological disorders like ovarian cancer.

Severe chronic neutropenia can exist from birth (congenital neutropenia) or cn occur an any time through life (acquired neutropenia). It may develop by itself or as an accompanying symptom of a different underlying disease. The following list gives you examples of the different types of chronic neutropenias.

The following list gives you examples of the different types of chronic neutropenias.
Neutropenias present at birth:

Severe congenital neutropenia (Kostmann syndrome) Cyclic neutropenia

Metabolic diseases associated with neutropenia

Shwachman-Diamond syndrome
Glycogen-storage disease type 1b Idiopathic neutropenia Autoimmune neutropenia

Neutropenias that are acquired during life

Infection Table 1 : Causes of non-malignant Neutropenia Infection Immunologic diseases Human immunodeficiency virus Parvovirus Hepatitis viruses Malaria Isoimmune neonatal Neutropenia Autoimmune Neutropenia Felty's syndrome Rheumatoid arthritis Sjogren's syndrome Systemic lupus erythematosus

Drug Induced Neutropenia Hematologic diseases Congenital Neutropenia or Kostmann's syndrome Cyclic Neutropenia Childhood idiopathic Neutropenia Adult idiopathic Neutropenia Shwachman's syndrome Myelokathexis syndrome Congenital immunologic deficiency syndromes Aplastic anemia Myelodysplastic syndromes

This grave and unpredictable disorder is characterized by severe Neutropenia caused by an idiosyncratic reaction reaction to a drug that results in either direct suppression or

immune destruction of neutrophils or myeloid precursors. Historically, women and older

individuals experience these reactions more commonly than men and younger patients. In addition, genetic factors appear to influence a particular individual's tendency to develop this type of reaction. Typically, Neutropenia becomes evident 1 - 2 weeks following an initial exposure to a drug, or swiftly following a recent re-exposure to any offending agent. Treatment consists of rapid withdrawal of any drug suspected of causing the idiosyncratic reaction. Unfortunately, therapy with cortcosteroids has not shown significant efficacy. A partial list of drugs that have been associated with druginduced Neutropenia is provided in Table 2.

Antibiotics Chloramphenicol Penicillin Sulfonamides

Antithyroid Agents Propythiouracil Tranquilizers Chlorpromazine

Analgesics/antiinflammatory agents
Aspirin Acetaminophen Phenylbutazone Sedatives Barbituates Benzodiazepines

Phenothiazines
Antirheumatics Gold Levamisole Penicillamine

What is Neupogen?
Neupogen (filgrastim) is a drug given to chemotherapy

patients who have neutropenia (low neutrophil count).

An injection of Neupogen stimulates white blood cell

production. It is a clear liquid that is usually given as a

shot (injection).

Use For Breast Cancer:

Chemotherapy for breast cancer affects all the rapidly dividing cells in

your body, including bone marrow cells, which produce white and red
blood cells and platelets. Fewer bone marrow cells means less blood cells overall. If your CBC shows that your neutrophil count is low, you

may be neutropenic. Injections of Neupogen can boost production of

your neutrophils, a special type of white blood cell that helps your body fight infection.

How Neupogen Works:

Usually, your body produces a protein that stimulates the production of neutrophils. But during chemo for breast cancer, your body may not make enough of this protein. Your CBC may reveal that your neutrophil blood counts are

low, and that you are neutropenic. Neupogen injections will

boost production of your neutrophils. You may feel aches and some bone pain while this drug is working, but it may help to imagine your immune system rebuilding itself and becoming stronger at protecting your health.

How Neupogen is Given:

You will have injections of Neupogen once daily, until your white blood cell counts return to normal levels. When properly given, these injections will not hurt. This drug can also be

given through an intravenous infusion (IV).

Some Common Side Effects of Neupogen:

Not everyone has side effects from Neupogen, but

here are the most common:

Bone

pain

Fever

Self-Care Tips:
Soak Take

in a warm bath to help reduce bone pain. Tylenol (acetaminophen) to help lower mild fever and

reduce pain.

Call Your Doctor if You Have These Symptoms:

unusual

fatigue and lethargy

chest

pain

heart

palpitations

mouth

sores

Urgent Symptoms include:

allergic

reaction (hives; problems breathing; swelling of

face, lips, tongue or throat; rash spreading over your

body)
abdominal shoulder

pain

pain

Antibiotics Chloramphenicol - Pentamycetin

Exerts bacteriostatic activity by binding with 50S subunit of ribosome and inhibiting protein synthesis

Serious infections when less potentially dangerous drugs are ineffective or contraindicated Adults: 50 to 100 mg/kg/day I.V. in divided doses q 6 hours, to a maximum dosage of 4 g/day Children: 50 to 75 mg/kg/day I.V. in divided doses q 6 hours Bacteremia or meningitis Children: 50 to 100 mg/kg/day I.V. in divided doses q 6 hours Ocular infections Adults and children: Instill two drops of ophthalmic solution in each eye q.i.d. As supplement to solution, apply small amount of ophthalmic ointment to conjunctival sac at bedtime. (Solution and ointment may be used together or alone.)

 Monitor patient for signs and symptoms of aplastic anemia, which may occur weeks or months after therapy ends. Monitor CBC count closely.

Assess hepatic enzyme levels in patients with hepatic disease.

Monitor creatinine levels in patients with renal insufficiency or failure.

Instruct patient to report bleeding or bruising, even if therapy ended several weeks or months earlier. Tell patient to report rash or itching.
Caution patient to avoid pregnancy during therapy. If shes using hormonal contraceptives, advise her to use additional birth control method (drug may make hormonal contraceptives ineffective). As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.

Sulfonamides
sulfadiazine microsulfon Sulfonamides Urinary tract infections due to susceptible microorganisms, chancroid, acute otitis media, Hemophilus influenzae, and meningococcal meningitis, rheumatic fever. hematologic changes, Stevens- Johnson

syndrome, nausea, vomiting, headache, diarrhea, chills, fever,

anoerexia, crystalluria, stomatitis, urticaria, and pruritus.

should be used cautiously in patients

with renal impairment, hepatic impairment, or bronchial asthma.

The nurse should advice that

sulfadiazine (Microsulfon) preparations should be at least 1 hour before or 2 hours after a meal. Notify the primary health care provider immediately if the following should occur: fever, skin rash or other skin problems, nausea, vomiting,

unusual bleeding or bruising, sore throat, or extreme fatigue.

Antithyroid Agents
Propythiouracil
PRESCRIBED FOR: PTU is used to manage hyperthyroidism associated with Graves' disease in patients who did not tolerate methimazole, and are not able to receive surgery or radioactive iodine therapy. It also is used to decrease symptoms of hyperthyroidism in preparation for surgical removal of the thyroid

gland or before radioactive iodine therapy in patients who did not tolerated
methimazole. DRUG INTERACTION : PTU may increase the effect of oral blood thinners, for example warfarin (Coumadin). Therefore, warfarin dose changes and monitoring for the effects of warfarin on blood clotting are necessary.

SIDE EFFECTS: The most common side effects are related to the skin and include rash, itching, hives, abnormal hair loss, and skin pigmentation. Other common side effects are swelling, nausea, vomiting, heartburn, loss of taste, joint or muscle aches, numbness and headache. Less common but serious side effects have occurred with PTU therapy. A decrease of white blood cells in the blood (agranulocytosis) may occur. Symptoms and signs of agranulocytosis include infectious lesions of

the throat, the gastrointestinal tract, and skin with an overall feeling of illness
and fever. A decrease in blood platelets (thrombocytopenia) also may occur. Since platelets are important for the clotting of blood, thrombocytopenia may lead to excessive bleeding. Severe liver injury and acute liver failure, in some cases fatal, have been associated with PTU. Some adults and pediatric patients required liver transplantation.

Tranquilizers
Action

Chlorpromazine
Unknown.May block postsynaptic dopamine receptors in brain and depress areas involved in

wakefulness and emesis. Also possesses anticholinergic, antihistaminic, and

adrenergicblocking properties. Indications Acute schizophrenia or mania

Preoperative sedation
Adults: 25 to 50 mg P.O. 2 to 3 hours before surgery, or 12.5 to 25 mg I.M. 1 to 2 hours before surgery Children ages 6 months to 12 years: 0.55 mg/kg P.O. (15 mg/m2) 2 to 3 hours before surgery, or 0.55 mg/kg I.M. 1 to 2 hours before surgery

Drug-behaviors. Alcohol use: increased CNS depression Sun exposure: increased risk of photosensitivity Patient monitoring Monitor blood pressure closely during I.V. infusion. Stay alert for signs and symptoms of neuroleptic malignant syndrome (hyperpyrexia,muscle rigidity, altered mental status, irregular pulse or blood pressure, tachycardia, diaphoresis, and arrhythmias). Stop drug immediately if these occur. Assess for extrapyramidal symptoms. Patient teaching Tell patient to take capsules or tablets with a full glass of water, with or without food. Instruct patient not to crush sustained-release capsules. Tell patient to mix oral concentrate in juice, soda, applesauce, or pudding.

Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.

PHENOTHIAZINES
USES: This medication is used to treat mental/emotional conditions. It is also used to treat nausea and vomiting and may be used for other conditions as determined by your doctor.

SIDE EFFECTS: Constipation, drowsiness, vision changes or dry mouth may occur. If any of these
effects persist or worsen, notify your doctor. This medication may cause dizziness and lightheadedness. To minimize these effects, get up slowly when rising from a seated or lying position. Unlikely to occur but report promptly: restlessness, muscle stiffness, weakness, difficulty

speaking, loss of balance, mask- like facial expression, trembling or shaking, dizziness, lip smacking
or other uncontrollable movements, difficulty urinating, skin rash/discoloration. Very unlikely to occur but report promptly: sore throat, unusual bleeding/bruising, stomach pain, yellowing of eyes/skin, dark urine, hot dry skin, vomiting. Though very unlikely to occur, notify your doctor

immediately if you experience any of the following effects: severe muscle stiffness, confusion, fever,
seizures, irregular/fast heartbeat, increased sweating, prolonged/painful erection. In the unlikely event you have an allergic reaction to this drug, seek immediate medical attention. Symptoms of an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing. If you notice other

effects not listed above, contact your doctor or pharmacist.

Analgesics/antiinflammatory agents
Acetylsalicylic Acid (Aspirin) - Aspergum
Pharmacologic class: Non-steroidal anti-inflammatory drug (NSAID) Therapeutic class: Nonopioid analgesic, antipyretic, antiplatelet drug Pregnancy risk category C (with full dose in third trimester: D) Action - Reduces pain and inflammation by inhibiting prostaglandin production. - Fever reduction mechanism unknown; may be linked to decrease in endogenous pyrogens in hypothalamus resulting from prostaglandin inhibition. - Exerts antiplatelet effect by inhibiting synthesis of prostacyclin and thromboxane A2.

Adverse reactions
hearing loss nausea vomiting GI bleeding thrombocytopenia hyponatremia hypokalemia, hypoglycemia wheezing rash hypersensiti vity reactions

Patient monitoring
Watch for signs and symptoms of hypersensitivity and other adverse reactions, especially bleeding tendency.
Stay alert for signs and symptoms of acute toxicity, such as diplopia, ECG abnormalities, generalized seizures, hallucinations, hyperthermia, oliguria, acute renal failure, incoherent speech, irritability, restlessness, tremor, vertigo, confusion, disorientation, mania, lethargy, laryngeal edema, anaphylaxis, and coma.

Monitor elderly patients carefully because theyre at greater risk for salicylate toxicity.
With prolonged therapy, frequently assess hemoglobin, hematocrit, International Normalized Ratio, and kidney function test results. Check salicylate blood levels frequently. Evaluate patient for signs and symptoms of ototoxicity (hearing loss, tinnitus, ataxia, and vertigo).

Acetaminophen (N-acetyl-p-aminophenol)
Drug classes: Antipyretic Analgesic (nonopioid)
Therapeutic actions: Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to

cause vasodilation and sweating, which helps dissipate heat.

Analgesic: Site and mechanism of action unclear.

Indications:
Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory

effects) Common cold, flu, other viral and bacterial infections with pain and fever Unlabeled
use: Prophylactic for children receiving DPT vaccination to reduce incidence of fever and pain

Nursing responsibilities.
Do

not exceed the recommended dosage. physician if needed for children < 3 yr; if needed for longer than 10 days; if

Consult

continued fever, severe or recurrent pain occurs (possible serious illness).

Avoid

using multiple preparations containing acetaminophen. check all OTC products.

Carefully Give

drug with food if GI upset occurs.

Discontinue drug if hypersensitivity reactions occur. of overdose: Monitor serum levels regularly, N-acetylcysteine should be

Treatment

available as a specific antidote; basic life support measures may be necessary.