Fifty-seven patients in initial phase of acute promyelocytic leukemia (APL) were treated in the same department with heparin infusion, platelet transfusions, and two related induction regimens both including cytosine arabinoside and daunorubicin. Clinical and biological findings at presentation were studied. The complete remission (CR) rate was 53%. Twenty-seven patients (47%) died during the initial course of the disease, either before day 5 (early death [ED], n = 7) or after day 5 (death in aplasia [DA], n = 20). Most ED was due to intracerebral hemorrhage (6/7), especially when large hemorrhages had been seen on fundus oculi examination. Most DA was due to multivisceral failure (9/20). No correlation was found between initial disseminated intravascular coagulation (DIC) and death. However, the worsening of coagulation parameters during induction therapy, with or without initial DIC, significantly increased the occurrence of renal and respiratory failure which were particularly frequent during the first month. The median duration of survival was short (3.5 months) and the median duration of CR (11 months) was similar to that of other acute myeloid leukemias treated with the same regimens. The possible causes of the high mortality observed during the initial courses of APL and the possible benefit of a more graduate induction chemotherapy are discussed.

Acute promyelocytic leukemia in 57 previously untreated patients.

A review of 58 patients with malignancies (age range, 14-73 years), who required surgical consultation for acute abdominal pain in the setting of neutropenia (granulocyte count less than 1000/mm3) after chemotherapy was conducted. Ninety percent had fevers greater than 37.8 degrees C, 30% had diarrhea or melena, and 25% had diminished bowel sounds. Five of the 29 patients (17%) with localized pain had surgical intervention; 3 of 29 patients (10%) with generalized pain underwent operations (2 for x-ray findings). All eight of these surgically treated patients survived to leave the hospital. Eighteen of the 29 patients with generalized pain were believed to have a similar syndrome of diarrhea (occasionally heme positive) and diffuse abdominal tenderness (some with peritoneal signs and distension), which was termed "neutropenic enteropathy." Eleven of these 18 patients had their symptoms resolve with antibiotic therapy, aggressive fluid replacement, and a return of their granulocyte count to normal. The other seven died of pneumonia (two), unknown causes (one), and diffuse enterocolitis throughout the intestinal tract (four documented at autopsy). The overall 30-day mortality rate in this series was 34%. Several factors correlated significantly with mortality: hypotension at the onset of pain (80% mortality), bacteremia (63% mortality), and fungemia (100% mortality). Absolute leukocyte count and absolute platelet count did not correlate with mortality. This study reaffirms that patients with neutropenic enteropathy are best treated conservatively. Patients with surgically correctable disease were identified by specific focal findings on examination or x-ray.

Abdominal pain in neutropenic cancer patients

Multidrug resistant (MDR) Gram-negative bacteria (GNB) have emerged as important pathogens and a serious challenge in the management of neutropenic patients worldwide. The great majority of infections are caused by the Enterobacteriaceae (especially Escherichia coli and Klebsiella spp.) and Pseudomonas aeruginosa, and less frequently Acinetobacter spp. and Stenotrophomonas maltophilia. A broader-spectrum empiric antibiotic regimen is usually recommended in patients with a history of prior bloodstream infection caused by a MDR GNB, in those colonized by a MDR GNB, and if MDR GNBs are frequently isolated in the initial blood cultures. In any situation, de-escalation to standard empiric regimen is advised if infection with MDR GNB is not documented.

Tackling antibiotic resistance in febrile neutropenia: current challenges with and recommendations for managing infections with resistant Gram-negative organisms

Resume Les manifestations oto-rhino-laryngologiques sont frequentes au cours des hemopathies malignes ou benignes. Revelatrices ou non de la maladie, elles sont rarement evocatrices par leur seul aspect clinique car non specifiques. Un bilan hematologique simple, oriente par l'examen clinique, de meme que des examens anatomopathologiques, permettent d'en preciser l'etiologie ou de les rapporter a l'hemopathie connue. Les auteurs decrivent successivement les hemopathies malignes, notamment les lymphomes non hodgkiniens et la maladie de Hodgkin, les maladies benignes des globules blancs qu'il s'agisse des agranulocytoses ou des deficits immunitaires constitutionnels ou acquis, les hemoglobinopathies et les troubles de l'hemostase. Le bilan et les traitements sont en regle assures par les hematologistes.

Manifestations oto-rhino-laryngologiques des hémopathies de l'adulte

Resume Les infections a cocci a Gram positif sont actuellement majoritaires chez les patients neutropeniques. La responsabilite en incombe aux staphylocoques a coagulase negative. Les facteurs de risque exposant aux infections a staphylocoques a coagulase negative sont la presence d'une voie veineuse centrale, une neutropenie profonde et durable et la presence de lesions de mucite oro-pharyngee de plus en plus frequentes avec l'intensification des chimiotherapies. La meticillino-resistance frequente impose le recours a un glycopeptide pour traiter efficacement ces infections. Les infections a Staphylococcus aureus sont moins frequentes mais nettement plus preoccupantes avec une mortalite pouvant etre extremement elevee notamment lorsqu'il s'y associe des localisations pulmonaires. Les infections a streptocoques restent redoutees en hematologie, non pas tant en raison de leur frequence mais a cause de l'evolution fulminante toujours possible. Les septicemies a streptocoques viridans surviennent preferentiellement dans un contexte de neutropenie profonde au cours de leucemies aigues myeloides traitees par cytarabine a haute dose. La porte d'entree est alors la muqueuse oro-pharyngee lesee par la chimiotherapie. Les infections a pneumocoques sont favorisees par des antecedents de splenectomie ou par une hypogammaglobulinemie. La neutropenie n'est pas un facteur de risque constant. Les affections malignes qui exposent le plus aux infections a pneumocoques sont la maladie de Hodgkin, le myelome multiple et les cancers bronchopulmonaires. Les septicemies a enterocoques sont rares, representant moins de 3 % des cas, mais sont egalement grevees d'une lourde mortalite.

Les infections à cocci à Gram positif en hématologie et en cancérologie

Two hundred bacterial septicemia occurring in neutropenic patients (PMN less than 1,000 microliter) were analyzed. Most of these patients had hematologic malignancies. The underlying disease, the degree of neutropenia the association of septic focus with the bacteremia, the responsive microorganisms and their evolution during hospitalization were studied as prognosis factors. The overall mortality was 32.5 p. 100. The mortality was higher in patients whose granulocyte count was lower than 500 microliter. The occurrence of major septic focus (pulmonary, perineal infection, diarrhea with abdominal distension, ORL, or cutaneous extensive focus) during bacteremia was a highly significant factor of bad prognosis. The mortality of bacteremias with and without major septic focus was respectively 62 p. 100 and 15 p. 100. A study of the distribution of the bacterias was performed in terms of mortality and duration of hospitalization. "Escherichia coli" and gram positive cocci were predominant during the two first days and mortality was then low. After that time, others Gram-negative bacterias appeared, especially "Pseudomonas aeruginosa" and the mortality was increasing until the twentieth day. Therefore, the authors raise the opportunity of antibiotic therapy according to the duration between the beginning of the hospitalization and the occurrence of sepsis in neutropenic patients. The role of the extensive use of a curative antibiotic association using colistine and nalidixic acid between 1974 and 1976 is discussed in the emergence of more gram positive cocci bacteremias between 1976 and 1978 than between 1974 and 1976 in the same intensive care unit.

Bacterial septicemia in neutropenia patients

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Bacterial septicemia in neutropenia patients