neutropenia in pediatrics
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Neutropenia in Pediatrics. Bradd Hemker MD Pediatric and Adolescent Hematology and Oncology Department of Pediatrics and Human Development Michigan State University. Objectives. Define neutropenia and risks associated with various levels of neutropenia - PowerPoint PPT PresentationTRANSCRIPT
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Neutropenia in Pediatrics
Bradd Hemker MDPediatric and Adolescent Hematology and OncologyDepartment of Pediatrics and Human Development
Michigan State University
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Objectives
• Define neutropenia and risks associated with various levels of neutropenia
• Review causes of neutropenia in childhood• Discuss proper initial evaluation and
management of neutropenia• Discuss when to refer to pediatric
hematologist
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Definition of Neutropenia
• Absolute Neutrophil Count (ANC)– ANC = WBC x (% bands + segs)
• Normal ANC: 1500/mm3
• Neutropenia– Mild: 1000-1500– Moderate: 500-1000– Severe: <500
• Age matters (slightly)
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Pediatric Neutropenias
• History– Recurrent infections– Recurrent oral ulcers
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Neutropenia Related Infection
• Risk of serious bacterial or fungal infection when ANC <500
• Also depends on bone marrow reserve– Inability to make neutrophils (SCN or
chemotherapy) = higher risk– Destruction of neutrophils (auto-immune) = lower
risk
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Causes of Neutropenia
• Acquired– Infection– Infiltrative bone marrow
disease– Immune mediated– Medication
• Congenital– Severe Congenital – Cyclic neutropenia– Chronic benign
neutropenia of childhood– Chronic neutropenia of
childhood– Benign Ethnic
Neutropenia– Schwachman Diamond
syndrome
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Infection related neutropenia
• Most common cause of low ANC in pedatrics• viral or bacterial– May be immune mediated• +/- anti-granulocyte antibodies
– Direct bone marrow suppression– Marginalization of neutrophils
• Treatment: none typically needed– May take 3-4 weeks or longer to resolve!
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Auto-Immune Neutropenia
• Often triggered by infection• May be part of broader auto-immune disorder• Anti-granulocyte antibodies positive• Treatment– +/- IVIG, steroids, GCSF– Only if severe infection (ie hospitalized)
• May take years to resolve!
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Neonatal Alloimmune Neutropenia
• Maternal antibodies to paternal antigens on fetal platelets
• Identical to Rh disease of newborn• Typically resolves spontaneously over weeks
to few months• Diagnosis: testing of parental blood
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Drug Induced Neutropenia Antibiotics
BactrimCiprofloxacinClindamycinVancomycin
MetronidazoleDoxycycline
Chemotherapy
NeuropsychotropicsRespiridoneValproic acid
PhenytoinCarbamazepine
Barbiturates
Antihypertensives & Antiarrythmics
AnalgesicsNSAIDSAspirin
Treatment?
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Congenital Neutropenias• Severe Congenital Neutropenia (Kostmann
Syndrome)– Incidence ~1/1,000,000– Severe infections early in life—pneumonia,
abscesses, etc – Inability to make neutrophils ANC very low– Typically diagnosed in infancy• Elastase 2 mutation (ELA-2)
– Treatment: GCSF
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Congenital Neutropenias
• Schwachmann Diamond Syndrome– Neutropenia, pancreatic insufficiency– Presents in 1st 10 years of life with steatorrhea,
growth failure and infections– Physical anomalies are common (cleft palate,
syndactyly, strabismus)
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Congenital Neutropenia
• Cyclic Neutropenia– Blood counts cycle every ~21 days • ANC most pronounced
– Recurrent fevers, bacterial infections when ANC low– Diagnosis• Standard = CBC twice weekly x 6 weeks• ELA-2 testing
– Treatment: GCSF if significant infectious history
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Congenital Neutropenia
• Chronic Neutropenia of Childhood– ANC often <500– Associated with significant infectious history– Diagnosis of exclusion• No evidence of cycling counts• Normal bone marrow• +/- anti-granulocyte antibodies
– Treatment: GCSF if significant infections
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Congenital Neutropenia
• Chronic Benign Neutropenia of Childhood– ANC often <500– Not associated with significant infectious history– Diagnosis of exclusion• No evidence of cycling counts• Normal bone marrow• +/- anti-granulocyte antibodies
– Treatment: GCSF if significant infections
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Congenital Neutropenia
• Syndrome associated neutropenia– Myelokathexis (WHIM syndrome)– Glycogen storage disease type 1– Mitochondrial disorders– Congenital cobalamin deficiency– X-linked agammaglobulinemia– Chediak-Higashi syndrome– GCSF receptor mutations
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Benign Ethnic Neutropenia
• Overall WBC and ANC vary by ethnic group– African Americans tend to run lower compared to
causcasians– ANC of 1100 may not be abnormal for some
patients! • Slightly low ANC without any signficant
infectious history may not require any further work up!
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Workup of Neutropenia
• History, exam– Recurrent infections– Recurrent oral ulcers
• Labs– CBC w/ differential– Anti-granulocyte antibodies
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Workup of Neutropenia
• If suspect post-infectious– Repeat labs in 3-4 weeks– if ANC remains low but improved and patient is
clinically well—repeat in another 3-4 weeks.– If no change over this time consider referral to
hematologist
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When to worry . . .
• ANC <500 with fever– hospitalization for blood cultures, IV antibiotics
• Worrisome history – Recurrent fevers, night sweats, weight loss,
enlarged lymph nodes, refusal to walk, bone pain• Worrisome exam– Lymphadenopathy, organomegaly
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When to Refer
• Persistently low ANC (< 1000) regardless of infectious history
• Mildly low ANC with significant infectious history
• Worrisome history or exam findings that are not improving as viral symptoms do . . .
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Pediatric Hematology Neutropenia Work-Up
• Detailed history regarding infections, ulcers, diarrhea, etc. • Repeat CBC w/ manual diff
– Review peripheral smear– Concern for other cytopenias or other WBC morphologic
abnormalities bone marrow asp/bx• Cyclic neutropenia work-up
– CBC twice weekly x 6 weeks– ELA2 gene testing
• Repeat counts every 2-4 weeks—less often if patient stable without ongoing infectious concerns
• Bone marrow evaluation
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Treatment of Neutropenia
• Granulocyte colony stimulating factor (GCSF)– 1-5 mcg/kg SQ • Daily• Three times per week• Weekly . . .
• When? – Symptomatic neutropenia (serious infection)– Prevention of neutropenia (if h/o serious infections)
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Chronic Neutropenia
• Children need evaluation with any fevers– CBC w/diff– Blood culture– +/- empiric antibiotics (ceftriaxone)
• If ANC < 500 hospitalize for IV antibiotics until blood cultures negative and ANC improving
• If ANC > 500 treat like any other child
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References• Donadieu et al. Congenital neutropenia: diagnosis, molecular bases and patient
management. Orphanet J Rare Dis. 2011;6:26• James RM, Kinsey SE. The investigation and management of chronic neutropenia
in children. Arch Dis Child. Oct 2006; 91(10): 852-858• Walkovich K, Boxer LA. How to approach Neutropenia in Childhood. Pediatrics in
Review. 2013;34;173• Horwitz et al. Neutrophil elastase in cyclic and severe congenital neutropenia.
Blood 2007, 109(5):1817-1824• Dale et al. Cyclic Neutropenia. Seminars in Hematology. 2002,39(2):89-94• Berliner et al. Congenital and Acquired Neutropenia. American Society of
Hematology Education Book. 2004, 1:63-79• Andersohn et al. Systematic Review: Agranulocytosis Induced by
Nonchemotherapy Drugs. Ann Intern Med. 2007;146:657-665