造血干细胞移植后早期感染29例临床分析

目的了解儿童脐血及外周血造血干细胞移植早期感染发生的情况及其影响因素.方法采用回顾性的临床统计,分析了造血干细胞移植早期感染的29例病例的临床资料.结果 31例造血干细胞移植患儿移植后早期感染的发生率为94%(29例).首次发生移植早期感染的时间为0～+22 d(移植后为"+"),中位时间+6.2 d,高峰时间为+4～+7 d;感染持续时间为3～20 d,中位时间8.9 d.二次感染的8例感染发生的时间为+13～+27 d,中位时间+18.8 d.所有29例患儿首次感染均发生在中性粒细胞绝对计数>0.5×109/L之前,移植后的WBC数量的恢复情况与移植后早期感染的发生和持续时间密切相关.移植早期感染最常见为口腔炎、胃肠炎等消化道粘膜炎,其次为呼吸道感染;本组病例血培养以G革兰阴性杆菌阳性率最高.移植早期预防性使用泰能较对照[(+4.7±2.1) d]可推迟首次感染发生的时间[(+8.6±5.1 )d].结论移植后早期感染发生的高峰时间为+4～+7 d,感染持续时间为3～20 d,中位时间8.9 d;主要为消化道粘膜炎及呼吸道感染;血培养阳性细菌以革兰阴性杆菌为主.移植前预防性使用亚胺培南+西司他丁(商品名泰能)可以推迟移植后早期感染的发生时间,对移植早期感染的预防有一定的效果.     

Hematological changes and predictors of bone marrow recovery in patients with neutropenic episodes in acute lymphoblastic leukemia

A total of 30 episodes of neutropenia in 16 patients of acute lymphoblastic leukemia, aged between 1 and 12 years were studied prospectively. In the initial treatment phase (induction of remission, consolidation and CNS prophylaxis) 92.8 per cent episodes were prolonged (> 7 days) and 85.7 per cent of them had profound neutropenia (absolute neutrophil counts < 0.200 x 10(9)/l). In contrast, in the maintenance phase, only 64.2 per cent were of prolonged duration; of them 57.1 per cent had profound neutropenia. Most patients in neutropenia of prolonged duration had anemia (Hb < 8 g/100 ml) and thrombocytopenia (platelet < 100 x 10(9)/l). Regularly increasing trends were seen in total leucocyte counts (TLC), absolute monocyte counts (AMC) and platelet counts from 4 days prior to recovery of absolute neutrophil counts (ANC). Of all the parameters, platelet count (> 100 x 10(9)/l) and AMC (> 0.1 x 10(9)/l) recovered 4 and 1 days, respectively, prior to recovery of ANC above 0.5 x 10(9)/l. Recovery of platelet counts (4 days prior to recovery of ANC) and possibly AMC can be considered early predictors of bone marrow recovery. These parameters can be used in conjunction with clinical condition to decide about early discharge of leukemia patients with neutropenia, especially in developing countries where prolonged stay can result in hospital acquired infections.     

Evaluation of risk prediction criteria for episodes of febrile neutropenia in children with cancer

PURPOSE: To evaluate the feasibility of risk stratification of children with cancer and febrile neutropenia using a simple set of criteria from data available to the clinician at the time of the patient's presentation. PATIENTS AND METHODS: This study is a retrospective cohort study of all children with cancer admitted to a single institution with fever and neutropenia (defined as an absolute neutrophil count < 500 cells/mm3) in a 1-year period. Patients were defined a priori as low risk if they were outpatients at the time of presentation with febrile neutropenia, had an anticipated duration of neutropenia less than 7 days, and had no significant comorbidity. All others were considered high risk. Data was analyzed by first admission for each patient and secondarily for all admissions for febrile neutropenia. RESULTS: There were 188 admissions in 104 patients for febrile neutropenia during the study period. Of these 47% were high risk and 53% were low risk. The duration of fever was not significantly different in the two groups. However, the duration of neutropenia and the length of hospital stay were significantly longer in the high-risk group. The frequency of bacteremia, other documented infection, and serious medical complications was significantly different in the two groups. Overall, the rate of any adverse event was 4% in the low-risk group versus 41% in the high-risk group. CONCLUSIONS: Simple criteria available to the clinician at the time of evaluation of the child with cancer who has fever and neutropenia allow the selection of a population at low risk for bacteremia or serious medical complication. A prospective study is planned using these risk criteria, evaluating outpatient oral antibiotic therapy in low-risk children with cancer.     

The safety of central line placement prior to treatment of pediatric acute lymphoblastic leukemia

BACKGROUND: Central venous lines are placed in children with acute lymphoblastic leukemia at diagnosis, despite significant cytopenias, to facilitate the administration of chemotherapy and blood sampling. The present study aimed to determine the safety of central line placement in these patients. METHODS: We reviewed the charts of 115 consecutive patients treated during a 10-year period. Data abstracted comprised age, gender, presenting and preoperative blood counts, type of central line, blood products transfused preoperatively, duration of neutropenia (absolute neutrophil count [ANC], <500/microl), treatment, and central line-associated complications. RESULTS: There were 66 male and 49 female patients with a median age of 4 years. Seventy-one patients were classified as standard-risk and 44 as high-risk. Respective median blood counts at diagnosis and prior to surgery were white cell count (microl), 4,200 and 5,550; hemoglobin (g/dl), 7.7 and 9.4; platelet count (microl), 63,000 and 72,000; and ANC (microl), 3,950 and 4,900. The median duration of neutropenia was 15 days in the standard-risk group and 18 days in the high-risk group. Thirty-eight patients were not transfused preoperatively. There were no episodes of bacteremia. Seven patients (7%) with life-ports experienced a complication: in four blood could not be aspirated, two ports needed realignment, and one a wound infection developed without dehiscence. Four patients (27%) with external lines had a complication: one each with line occlusion, accidental removal by patient, line rupture, and line leakage at insertion site. The complication rate between ports and external lines was different (P = 0.045). CONCLUSIONS: Central line placement prior to anti-leukemia treatment is safe. Most complications are mechanical and not due to leukemia, chemotherapy, or cytopenias.     

Transient neutropenia of childhood

Patient characteristics and clinical course are described in 21 children with newly discovered neutropenia (absolute neutrophil count less than 1500/microliter). Only children over age 3 months are included; 19 of 21 were less than age 2 years. The majority had respiratory tract infections and 11 had been on various medications at the time neutropenia was discovered. Bacteria were isolated from the blood of three patients (S. pneumoniae in two, H. influenzae in one) and from urine in one (E. coli). Respiratory syncytial virus was cultured from the nasopharynx of two patients. Opportunistic, gram-negative and staphylococcal infections did not occur. Neutrophil counts in all but one child returned to normal within 6 weeks of onset; half recovered within 7 days. Bone marrow examination was performed in 13 patients: maturation arrest at various stages in the myeloid series was noted in six, and seven had normal myeloid maturation. Bone marrow findings did not correlate with degree or duration of neutropenia. These observations indicate that previously well infants with isolated neutropenia generally have a benign clinical course, although three patients were ultimately proven to have significant chronic illness. Recommendations are made as to management.     

Hematologic predictors of bone marrow recovery in neutropenic patients hospitalized for fever: implications for discontinuation of antibiotics and early discharge from the hospital.

We evaluated the timing and pattern of changes in the complete blood cell count that preceded marrow recovery during 107 consecutive episodes of fever and neutropenia in 64 children with cancer. Four measures derived from serial daily measurement of the complete blood cell count were evaluated: total leukocyte count, absolute neutrophil count, absolute phagocyte count, and platelet count. During 70 (65%) of these 107 episodes, patients were discharged with an absolute neutrophil count of fewer than 500 cells/mm3; 24 patients were discharged from the hospital despite an absolute neutrophil count of fewer than 100 cells/mm3. During all but one of these 70 episodes, however, signs of early marrow recovery were present before discharge; sustained increases were observed in these patients' leukocyte, absolute neutrophil, absolute phagocyte, and platelet counts 2 or more days before their discharge in 41%, 49%, 50%, and 39% of cases, respectively. Although they were neutropenic at discharge, most patients had signs of multilineage marrow recovery at that time; 59 of 70 had increases in three of four of the measurements that we studied. None of the 69 patients who had evidence of marrow recovery at discharge had recurrence of fever. We conclude that children with cancer who were hospitalized for fever during periods of neutropenia have increases in the peripheral blood cell count that herald imminent bone marrow recovery, often several days before the absolute neutrophil count recovers to 500 cells/mm3. Our success in discharging such patients before resolution of neutropenia suggests that further controlled trials are needed to evaluate the safety and feasibility of cessation of antibiotic therapy and early discharge from the hospital.     

Neutropenia, neutrophil dysfunction, and inflammatory bowel disease in glycogen storage disease type Ib: results of the European Study on Glycogen Storage Disease type I

OBJECTIVE: To investigate the incidence, the severity, and the course of neutropenia, neutrophil dysfunction, and inflammatory bowel disease (IBD) in glycogen storage disease (GSD) type Ib. METHOD: As part of a collaborative European Study on GSD type I, a retrospective registry was established in 12 European countries that included all patients with GSD-I who were known at the centers and were born from 1960 to 1995. Of a total of 288 patients with GSD-I, 57 who had GSD-Ib form the basis of this study. RESULTS: Neutropenia (defined as an absolute neutrophil count <1 x 10(9)/L) was found in 54 patients. In 64% of the patients neutropenia was documented before the age of 1 year, but in 18% of the patients neutropenia was first noted between the ages of 6 and 9 years. Neutropenia was persistent in 5 patients and intermittent without any clear cyclical course in 45. Neutrophil function was investigated in 18 patients with neutropenia and was abnormal in all. Perioral infections were reported in 37 patients, perianal infections in 27 patients, and protracted diarrhea in 23 patients. Findings on colonoscopy and radiologic studies in 10 of 20 patients suspected to have IBD were abnormal in all. All patients with IBD, perioral infections, and perianal infections had neutropenia. CONCLUSIONS: Intermittent severe neutropenia is frequently found in patients with GSD-Ib. The study also indicates that IBD in GSD-Ib is underdiagnosed; up to 77% of the patients studied had evidence of IBD, all of whom had neutropenia. IBD was not detected in those with normal neutrophil counts. These findings support the notion that neutropenia and/or neutrophil dysfunction in GSD-Ib and IBD are causally related.     

Imipenem–cilastatin versus piperacillin–tazobactam as monotherapy in febrile neutropenia

Background: In view of the recent trend toward monotherapy in the treatment of febrile neutropenia, we evaluated the clinical efficacy and safety of imipenem–cilastatin versus piperacillin–tazobactam as an empiric therapy for febrile neutropenia in children with malignant diseases. Methods: Febrile neutropenic patients received either imipenem–cilastatin or piperacillin–tazobactam randomly. Improvement without any changes in the initial antibiotic treatment was defined as “success” and improvement with modification of the initial treatment and death was defined as “failure”. Results: Over 12 months, 99 febrile neutropenic episodes were treated with monotherapy in 63 patients with a median age of 5 years. At admission, median absolute neutrophil count was 50/mm³ and in 67% of episodes, neutrophil count was under 100/mm³. Median duration of neutropenia was 5 days. In 22% of episodes, neutropenia persisted for more than 10 days. Piperacillin–tazobactam was used in 52 episodes and imipenem–cilastatin was used in 47 episodes. There was no difference between groups in terms of age, sex, primary diseases, neutrophil count or duration of neutropenia. In the whole group, the success rate was 67% and the failure rate was 33%, whereas in the piperacillin–tazobactam group, the rates were 71% and 29%; and in the imipenem–cilastatin group they were 62% and 38%, respectively (P > 0.05). There were no deaths. No major adverse effects were seen in either group. Conclusions: Although failure was slightly higher in the imipenem–cilastatin group, this was statistically insignificant. Both of these antibiotics can be used safely for initial empirical monotherapy of febrile neutropenia.     

Pediatric Hematology: Methods and Protocols

Forty-one children were identified with autoimmune neutropenia of infancy and early childhood (absolute neutrophil count [ANC] less than 500/μ and demonstrable serum antineutrophil antibodies). There were 21 boys and 20 girls; the median age at diagnosis was 11 months (range 5–38 months). No life-threatening infections occurred. There was a gradual upward trend in ANC in all patients over many months, with 87% having an ANC >1000/μl by 24 months from diagnosis. Among various clinical and laboratory parameters analyzed statistically, only younger age at diagnosis was associated with earlier neutrophil recovery. There was no association between degree or duration of neutropenia and sex, race, antibody reactivity, or presence of serious illness at diagnosis.     

Granulocyte colony-stimulating factor in glycogen storage disease type 1b. Results of the European study on glycogen storage disease type 1

Patients with glycogen storage disease type 1b (GSD-1b) have neutropenia and neutrophil dysfunction that predispose to frequent infections and inflammatory bowel disease (IBD), for which granulocyte colonystimulating factor (GCSF) is given. To investigate the use and the value of GCSF treatment in GSD-1b, a retrospective registry of GSD-1 patients born between 1960 and 1995 in 12 European countries was established. Included were 57 GSD-1b patients. Unglycosylated GCSF was given to 18 patients, median age of starting therapy was 8 years, longest duration of therapy 7 years. Dose varied between 2–10 μg/kg, with a frequency from daily to twice per week. Neutropenia (defined as an absolute neutrophil count <0.5×10⁹/1) was found in 49 patients. In untreated patients, a significant decrease of haemoglobin, platelet counts and leucocyte counts with increasing age (P<0.032,P<0.04 andP<0.001 respectively) was noted, whereas neutrophil counts remained low but stable with increasing age. In nine patients who were treated longer than 1 year, median neutrophil counts increased significantly and simultaneously median leucocyte counts and platelet counts decreased significantly. In all patients treated, the number and severity of infections decreased and the severity of IBD improved subjectively. The most serious complication of GCSF treatment was marked splenomegaly (four patients).Conclusion: in this retrospective study a significant haematological effect was documented and a subjective improvement of infections and inflammatory bowel disease. In view of the uncertainty, prospective controlled trials seem warranted to clarify the indication for the use of granulocyte colony-stimulating factor in this disease. Published online: 17 July 2002     

Randomized comparison of antibiotics with and without granulocyte colony-stimulating factor in children with chemotherapy-induced febrile neutropenia: a report from the Children's Oncology Group

PURPOSE: To determine if granulocyte colony-stimulating factor (G-CSF) with empirical antibiotics accelerates febrile neutropenia resolution compared with antibiotics without it. PATIENTS AND METHODS: Eligible children were treated without prophylactic G-CSF and presented with fever (temperature >38.3 degrees C) and neutropenia afterward. Patients with acute myelogenous leukemia and myelodysplastic syndrome were excluded. Assignments were randomized between G-CSF (5 microg/kg/day) or none beginning within 24 hr of antibiotics. Subcutaneous administration was recommended, but intravenous G-CSF was allowed. Patients remained on study until absolute neutrophil count (ANC) >500/microl and > or =48 hr without fever. RESULTS: One of 67 patients enrolled was ineligible, 59 had acute lymphoblastic leukemia (ALL). Thirty-four were assigned to antibiotics, 32 to G-CSF plus antibiotics. Adding G-CSF significantly reduced neutropenia and febrile neutropenia recovery times. Median days to febrile neutropenia resolution was nine earlier with G-CSF (4 vs. 13 days) (P < 0.0001). However, there was no difference in the resolution of fever between arms. Hospitalization median was shorter by 1 day with G-CSF (4 vs. 5 days) (P = 0.04). There was no difference in the duration of IV and oral antibiotic treatment, addition of antifungal therapy, and shock incidence. A trend for decreased incidence of late fever with G-CSF was noted (6.3 vs. 23.5%) (P = 0.08). CONCLUSIONS: Adding G-CSF to empiric antibiotic coverage accelerates chemotherapy-induced febrile neutropenia resolution by 9 days in pediatric patients, mainly with ALL, which results in a small but significant difference in the median length of hospitalization.     

Congenital neutropenia and primary immunodeficiency disorders: a survey of 26 Iranian patients

Inherited neutropenia is characterized by a decrease in the absolute number of circulating neutrophils and an increased susceptibility to infections. The current study was performed to determine the clinical and laboratory findings of Iranian patients with inherited neutropenias. Records of 26 patients (14 male, 12 female) with inherited neutropenia were reviewed in this study. The patients had been referred to Children's Medical Center, a referral center for immunodeficiency disorders in Iran, during a 22-year period (1981-2003). Primary immunodeficiency disorders of these patients were as follows: cyclic neutropenia (8 patients), Shwachman-Diamond syndrome (7 patients), Kostmann syndrome (6 patients), and Chediak-Higashi syndrome (5 patients). The mean absolute neutrophil count of patients was 398.2 +/- 259.3 cells/mm (range 74-1,152/mm) at the first visit. Twenty-one patients showed severe, four moderate, and one mild neutropenia. Sixteen of these patients had leukopenia, seven anemia, two thrombocytopenia, and one monocytosis. The most common presenting complaints in these patients were oral ulcer, otitis, pneumonia, diarrhea, cutaneous abscess, and oral candidiasis. The patients first manifested symptoms of infection suggesting neutropenia at a median age of 7.5 months (range 1 month to 10 years). During follow-up, respiratory infections developed in 24 cases, oral manifestations in 20 patients. The most common infections, in descending order of frequency, were otitis media, abscesses, pneumonia, oral ulcers, acute diarrhea, cutaneous infections, oral candidiasis, and periodontitis. Less frequent infections were sinusitis, cystitis, conjunctivitis, meningitis, and osteomyelitis. Nonspecific symptoms (hepatomegaly and splenomegaly) were also detected in 10 patients and 1 patient, respectively. Three patients died of recurrent infections. The infectious manifestations both at presentation and during follow-up in inherited neutropenia were similar. Although inherited neutropenias are rare, recurrent infections always deserves further evaluation for detecting such disorders.     

Myelosuppression associated with co-trimoxazole as a prophylactic antibiotic in the maintenance phase of childhood acute lymphocytic leukemia

Thirty-seven children with acute lymphocytic leukemia in clinical remission for at least 6 months completed a 1-year trial in which they were randomly assigned in a double-blind fashion to receive co-trimoxazole twice daily for 6 months followed by placebo for 6 months (18 patients) or placebo followed by co-trimoxazole (19 patients). Total amounts of maintenance chemotherapy administered during both periods were similar. During administration of co-trimoxazole significant reductions were documented in the patients' average total white blood count (P less than 0.001), absolute neutrophil count (P less than 0.001), absolute lymphocyte count (P = 0.009), and platelet count (P = 0.002) compared with values obtained during the placebo period. Patients had on the average 1.6 infections during the co-trimoxazole period compared with 2.5 infections during placebo administration (P = 0.008). It is concluded that, although co-trimoxazole is an effective prophylactic antibiotic in children with acute lymphocytic leukemia, the resultant myelosuppression could potentially hamper the administration of maintenance cancer chemotherapy.     

Pegfilgrastim in children with severe congenital neutropenia

Two pediatric patients affected by severe congenital neutropenia (SCN) were treated with 100 mcg/L/dose every 9–12 days within a pilot study (Observatory of the Italian Ministry of Health, Eudract Code 2005‐003096‐20) on the use of pegfilgrastim in patients with chronic neutropenia. Both children increased their absolute neutrophil count, reduced their infectious load, and improved their quality of life. Serum concentrations of G‐CSF observed in pegfilgrastim mirrored those seen in filgrastim. These data suggest that pegfilgrastim may be beneficial in SCN patients with an exposure of hematopoietic cells to G‐CSF similar to that on filgrastim. Pediatr Blood Cancer 2010;54:465–467. © 2009 Wiley‐Liss, Inc.     

Transient neutropenia in children with febrile illness and associated infectious agents: 2 years’ follow-up

The aim of the study was to identify the relationship of acquired neutropenia with childhood infections and to assess its clinical course, complications, and outcome. Children admitted to two pediatric wards over a 4-year period with febrile neutropenia were prospectively investigated for underlying infections with inflammatory markers, cultures of body fluids, and serological tests. The study included 161 previously healthy children with febrile neutropenia/leukopenia aged (mean?±?SD) 3.02?±?3.86 years (range, 0.1–14). One hundred and thirty-six out of 161 patients (84.5 %) had transient neutropenia (TN), while in 25 patients, neutropenia was chronic (CN) and persisted for ≥180 days. An infectious agent was isolated in 98/161 (60.9 %) cases, in 68.4 % patients with TN, and in 20 % of those with CN (p?=?0.001). Among the patients with CN, seven had positive antineutrophil antibodies (autoimmune neutropenia) and four were eventually diagnosed with hematological malignancy. In all age groups, TN was of short duration (<1 month), of mild to moderate severity, and was predominantly associated with viral infections. Two years after diagnosis, 143/161 children (88.8 %) were available for follow-up. One hundred and thirty-seven of 143 (95.8 %) had recovered completely, while the rest remained neutropenic. The latter patients had a benign course despite severe neutropenia. In conclusion, febrile neutropenia during childhood is usually transient, often following viral and common bacterial infections, without serious complications and in the majority of cases it resolves spontaneously. However, in a considerable percentage of patients, neutropenia is discovered incidentally during the course of an infection on the ground of an underlying hematological disease.     

Totally implantable central venous access devices in children with hemato-oncologic malignancies: evaluation of complications and comparison of incidence of febrile episodes with similar patients without central venous access devices

The incidence of mechanical and infectious complications of totally implantable central venous access devices (TIDs) must be related to underlying disease, intensity of the chemotherapy, and frequency of manipulations. Records of the patients hospitalized from January 2002 to May 2005 were evaluated. Patients with TIDs were matched with patients without TIDs having the same malignancy and the same anti-neoplastic chemotherapy. Catheter-related complications were documented and corresponding phases of the chemotherapy in matched pairs were compared with regard to infections. TIDs were inserted in 31 patients with a median age of 4.3 years (22 acute leukemia, 1 NHL, and 8 solid tumors). Total number of catheter days was 5268, with a median catheter life of 174 days (range 9-493 days). Nine catheters (29%) were removed due to mechanical and infectious complications. There was 13 catheter-related infections with a rate of 2.46/1000 catheter days. Total number of mechanical complications was 5 and overall rate of complications was 3.41/1000 catheter days. The rate of febrile episodes was 54 and 41 in the TID and no TID group, respectively (p: .11). Duration of neutropenia was 9.6 and 7.4 days and duration of fever per febrile attack was 5.6 and 4.4 days in the TID and no TID group, respectively (p: .047 and .56). Although most of the patients in this study had hematological malignancy and required frequent manipulation, the results were similar to those in developed countries. TIDs are essential for management of chemotherapy in pediatric malignancies with acceptable complications.     

Immature neutrophils in the blood smears of young febrile children

OBJECTIVE: To determine whether the immature neutrophil (band) count in the peripheral blood smear helps to distinguish young febrile children with bacterial or respiratory viral infections. DESIGN AND SETTING: A prospective cohort study in 3 pediatric emergency departments. PATIENTS: A convenience sample of 100 febrile children aged 2 years or younger with either laboratory-documented bacterial infections (n = 31; 24 with urinary tract infections, 7 with bacteremia) or laboratory-documented respiratory viral infections (n = 69). Each patient received a clinical appearance score using the Yale Observation Scale prior to laboratory evaluation. A complete blood cell count was obtained from all patients and manual differential count of the peripheral blood smear was performed by 1 senior technician masked to clinical information. MAIN OUTCOME MEASURE: Band counts, represented as a percentage of white blood cells in the peripheral blood smear, the absolute band count, and band-neutrophil ratio. Logistic regression analysis was performed to determine whether the band count helps to distinguish bacterial infections from viral infections after adjusting for age, temperature, Yale Observation Scale score, and absolute neutrophil count. RESULTS: Patients with bacterial infections had a higher mean absolute neutrophil count (11.3 vs 5.9 x 10(9)/L; P<.01) than patients with respiratory viral infections. There was no difference, however, in percentage band count (13.5% vs 13.3%; P = .90), absolute band count (2.2 vs 1.9 X 10(9)/L; P= .31), or band-neutrophil ratio (0.24 vs 0.33; P = .08, bacterial vs viral, respectively); the band count did not help to distinguish bacterial and viral infections after adjusting for age, temperature, Yale Observation Scale score, and absolute neutrophil count in the regression analysis. CONCLUSION: The band count in the peripheral blood smear does not routinely help to distinguish bacterial infections from respiratory viral infections in young febrile children.     

Neonatal neutropenia. Clinical manifestations, cause, and outcome

Neutropenia, defined as an absolute neutrophil count that falls below 2.0 x 10(9)/L, is being identified more frequently in the newborn intensive care unit and significantly influences clinical decisions regarding therapy. We prospectively identified 119 episodes of neutropenia in 87 infants (6% of admissions). Less than half of the episodes could be attributed to infections. The majority of noninfectious neutropenia episodes were related to specific perinatal events or were of unknown cause. Infants weighing less than 2500 g were more likely to have neutropenia than term infants (13% vs 3%, respectively) and less likely to have neutropenia related to bacterial infections. Short-term survival (89% vs 95%) and long-term survival (74% vs 77%) were not different in infants with infectious diseases compared with those with noninfectious diseases. Mortality was highly correlated with the need for assisted ventilation (20%) or with an absolute neutrophil count of 0.5 x 10(9)/L (24%). We conclude that the cause of neutropenia and the clinical condition must be carefully evaluated before instituting aggressive therapy for infection.     

Effect of lithium carbonate plus oxymetholone vs. lithium alone on chemotherapy-induced myelosuppression

To evaluate the possible additive leukocyte count-enhancing properties of lithium and oxymetholone, patients (1-21 years old) were randomized to receive lithium or lithium plus oxymetholone after chemotherapy. Seventy-one trials with lithium, 63 with both drugs, and 79 in the control group, were compared. White blood cell count and neutrophil nadirs were better in both treatment groups than in the controls (p = 0.001) but an additive effect of oxymetholone above and over lithium alone was seen only in patients under 15 years old (p = 0.05). The median duration of severe neutropenia (absolute neutrophil count less than 1000/cm3) was 6.2 days/patient in the control group but only 4.5 days/patient and 3.8 days/patient in the lithium and lithium plus oxymetholone groups, respectively (p = 0.0001). Both the lithium and lithium plus oxymetholone treatments had a modest platelet-sparing effect (p = 0.03). No difference in the hemoglobin nadirs was observed in the three groups. While the majority of the patients lost weight in the control and lithium-treated group, the patients on oxymetholone gained weight (median 1.25 kg) p = 0.00001. Lithium reduces the period of neutropenia after chemotherapy during which the patients may acquire infection. The addition of oxymetholone does not substantially lessen myelosuppression in most patients but improves the patients' appetite and weight.     

Neutropenia in antibody-deficient patients under IVIG replacement therapy

Patients with antibody deficiencies are more prone to develop acute neutropenic episodes even during immunoglobulin replacement. The aims of this study were to evaluate the presence of acute neutropenia in 42 patients with primary antibody immunodeficiencies, currently receiving intravenous immunoglobulin (IVIG), and to describe the clinical and laboratory findings during neutropenic episodes. Of all patients, 10 (23.8%) presented acute neutropenia (absolute neutrophil count <1500 cells/mm³) during follow up (mean of 6.4 yr). The absolute neutrophil count ranged from 71 to 1488 cells/mm³. Neutropenia was not clearly associated with antibiotic prophylactic therapy or immunoglobulin levels, while infections were associated with neutropenia in the majority of episodes. Most acute neutropenia episodes were mild or moderate, except in CVID patients who present more severe neutropenia. Although IVIG may have contributed to reducing the severity of neutropenia, it does not prevent its occurrence in all patients. In conclusion, primary immunodeficient patients, even submitted to IVIG replacement therapy, must be regularly evaluated for neutropenia in order to minimize the risk of infections and its appropriate approach.