First Report of an Invasive Infection by Cephalotrichum gorgonifer in a Neutropenic Patient with Hematological Malignancy under Chemotherapy

The etiological agents of infrequent invasive fungal infections (IFI) are difficult to identify on the species level using classic morphological examination. We describe the first case of an IFI caused by Cephalotrichum gorgonifer in a neutropenic patient with a hematological malignancy and put it on the map as a new causative agent of IFI. Case report, microbiological findings and description of the etiological agent. A 60-year-old man was diagnosed with mantle cell lymphoma. A CT scan confirmed the presence of lung infiltrates located at the right upper lobe. Histological examination of one of the nodules showed a large number of narrow septate hyphae with acute-angle branching and irregular round cell morphology; vessels walls appeared infiltrated, proving an angioinvasive pulmonary IFI. Sample culture resulted positive and molecular identification proved the presence of Cephalotrichum gorgonifer. Voriconazole was used for 12 months and the patient did not report any complications or side effects. Complete remission of lymphoma was achieved later by the time chemotherapy, radiotherapy, and radioimmunotherapy consolidation were completed. We recommend the inclusion of Cephalotrichum gorgonifer in the list of opportunistic pathogens causing mycoses in neutropenic hematological patients with suspected mould-related IFI.

Diagnosis and therapeutic decision-making for the neutropenic patient

Determining the cause of a low neutrophil count in a pediatric or adult patient is essential for the hematologist's clinical decision-making. Fundamental to this diagnostic process is establishing the presence or lack of a mature neutrophil storage pool, as absence places the patient at higher risk for infection and the need for supportive care measures. Many diagnostic tests, eg, a peripheral blood smear and bone marrow biopsy, remain important tools, but greater understanding of the diversity of neutropenic disorders has added new emphasis on evaluating for immune disorders and genetic testing. In this article, a structure is provided to assess patients based on the mechanism of neutropenia and to prioritize testing based on patient age and hypothesized pathophysiology. Common medical quandaries including fever management, need for growth factor support, risk of malignant transformation, and curative options in congenital neutropenia are reviewed to guide medical decision-making in neutropenic patients.

Recurrent Diverticulitis in a Neutropenic Patient: A Case Report

Background: Neutropenic patients are at an increased risk of infections. These infections can originate from several sites including the respiratory, urinary or gastrointestinal systems. Diverticulitis is one such infection, that carries a high morbidity and mortality risk in such patients. The management remains controversial and involves deciding between a conservative medical approach and surgical intervention. Regardless, these patients should be closely monitored due to a high risk of developing complications including septic shock. Case Report: In this article, we discuss the case of a patient with acute myeloid leukemia (AML) presenting with neutropenic fever and found to have a recurrent episode of diverticulitis. The patient was quickly managed with medical therapy, and surgery was therefore deferred. Conclusion: In conclusion, physicians should always maintain diverticulitis as a differential diagnosis in neutropenic patients who present with abdominal pain, especially in those who have had a previous episode. This allows for rapid and more efficient management.

#32: Quality Improvement Strategies in the Management of Fever in Children with Cancer in a Third-level Hospital in Bolivia

Background The care of children with cancer requires systematic and standardized management to avoid complications associated with treatment, one of which is infection. Fever is an important sign of infection in a neutropenic patient and requires early management to avoid unfavorable outcomes. Many factors contribute to delays in recommended steps of fever management. The objective of this project was to measure the delay times associated with key steps in fever management and identify challenges and opportunities to improve this care process. Methods A prospective quality improvement project was initiated between June and November 2019 at the 25-bed oncology service of the Dr. Ovidio Aliaga Uria Children’s Hospital in La Paz. A data collection sheet was constructed and implemented including times for fever identification, blood culture collection, antibiotic order, and antibiotic administration. In parallel, we worked with the health personnel of this unit to deconstruct the process of fever management using block and flow diagrams. We jointly constructed an impact/effort matrix to prioritize key interventions. These interventions were developed to be implemented to improve this process. Results During these 6 months, data from 29 neutropenic patients who had a fever was collected. The average time elapsed from fever identification until blood culture collection was 4.9 hours (n = 28), time elapsed from fever to antibiotic initiation was 7.3 hours (n = 27), time between antibiotic order and administration was 1.6 hours (n = 26), and time between blood culture collection and antibiotic administration was 2.3 hours (n = 26). The interventions proposed through the effort/impact matrix as low effort and of high impact were: priority attention of pediatric oncology patients in the emergency department through the implementation of a patient identification card to expedite the admission process, development of a fever management flowchart with a record of action schedule and improve the availability of bottles for blood culture. Conclusions Our results demonstrate that delays exist in the management of fever in children with cancer in our hospital. Identifying the gaps and pivotal steps in the process, and opportunities for improvement are the first key steps toward implementing strategies to improve the quality of care. Categorization, testing, and execution of standardized interventions will help to improve fever management and must be done as a collaborative effort between departments involved in pediatric neutropenic patient care such as infectious diseases, pediatrics, and oncology. Our next steps include (1) training of medical and nonmedical staff involved in the admission and discharge processes to implement the patient identification card distribution and usage, (2) improving interdepartmental communication, and (3) identification of new opportunities for quality improvement to be tested and implemented.