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Matushita L, Valera ET, Aragon DC, Scridelli CA, Roxo-Junior P, de Carvalho LM. Chronic neutropenia in childhood: experience of a tertiary center. J Pediatr (Rio J) 2024; 100:311-317. [PMID: 38182128 PMCID: PMC11065660 DOI: 10.1016/j.jped.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE To assess the prevalence of chronic neutropenia (CN) and the clinical profile of patients with CN aged up to 18 years, followed in the pediatric hematology, rheumatology, or immunology outpatient clinic of a tertiary medical center from May 1, 2018, to 30 April 2019. METHODS Retrospective observational study carried out by collecting data from the patient's medical charts. CN was defined as absolute neutrophil count (ANC) below 1.5 × 109/L lasting over three months. Autoimmune neutropenia (AIN) was defined by clinical criteria and an over twofold increase in ANC after glucocorticoid stimulation. AIN was considered secondary when associated with autoimmune or immunoregulatory disorders. Wilcoxon and Fisher's exact tests were used to compare variables; the significance level was 5 %. RESULTS A total of 1,039 patients were evaluated; 217 (20 %) presented CN. Twenty-one (2 %) had AIN, classified as primary in 57 % of the cases. The average age at the onset of symptoms was 38.6 months. During follow-up, patients had 4.2 infections on average; frequency was higher among patients with secondary AIN (p = 003). Isolated neutropenia occurred in 43 % of the patients with AIN. Neutropenia resolved in eight (38 %) of the 21 patients with AIN within 19.6 months on average. Eight patients with secondary AIN met the criteria for Inborn Errors of Immunity. CONCLUSION AIN prevalence was 2 %. Most cases were first evaluated by a pediatric immunologist or rheumatologist rather than a pediatric hematologist. This study highlights the need for a multidisciplinary approach involving a pediatric immunologist, rheumatologist, and hematologist.
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Affiliation(s)
- Letícia Matushita
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Pediatria, Ribeirão Preto, SP, Brazil
| | - Elvis Terci Valera
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Pediatria, Divisão de Oncologia e Hematologia, Ribeirão Preto, SP, Brazil
| | - Davi Casale Aragon
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Pediatria, Ribeirão Preto, SP, Brazil
| | - Carlos Alberto Scridelli
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Pediatria, Divisão de Oncologia e Hematologia, Ribeirão Preto, SP, Brazil
| | - Persio Roxo-Junior
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Pediatria, Divisão de Imunologia e Alergia, Ribeirão Preto, SP, Brazil
| | - Luciana Martins de Carvalho
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Pediatria, Divisão de Reumatologia Pediátrica, Ribeirão Preto, SP, Brazil.
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Chok R, Price V, Steele M, Corriveau-Bourque C, Bruce A. Pediatric Benign Neutropenia: Assessing Practice Preferences in Canada. J Pediatr Hematol Oncol 2022; 44:318-322. [PMID: 35129142 DOI: 10.1097/mph.0000000000002427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
Pediatric benign neutropenia is a self-limited condition with a benign clinical course. An approach to this condition is not well-defined in the literature. Our objective was to use a case-based survey to elucidate trends in the diagnosis and management of benign neutropenia among pediatric hematology/oncology practitioners in Canada. We received 46 completed surveys (response rate 66%). At initial presentation with fever and neutropenia, 67% of respondents recommended partial septic workup but 11% recommended no investigations. Nearly 70% recommended admission for empiric intravenous antibiotics, while 24% would discharge home without antibiotics. In a patient with fever and known neutropenia, respondents were more likely to pursue outpatient antibiotic therapy. For investigation of chronic neutropenia, most respondents (60%) do not use antineutrophil antibody testing. Common indications for bone marrow biopsy were severe infection, prolonged neutropenia, or before initiating granulocyte colony stimulating factor. Indications for granulocyte colony stimulating factor were based on severity and frequency of infection. Most respondents (84%) would not recommend antibiotic prophylaxis. Results demonstrate the considerable variability in management of benign neutropenia among pediatric hematology/oncology practitioners in Canada and highlight the need for prospective studies to establish diagnostic criteria for benign neutropenia and evaluate management of fever in this population.
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Affiliation(s)
| | - Victoria Price
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - MacGregor Steele
- Department of Pediatrics, Section of Pediatric Hematology, Alberta Children's Hospital and University of Calgary, Calgary, Alberta
| | - Catherine Corriveau-Bourque
- Division of Hematology/Oncology, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton
| | - Aisha Bruce
- Division of Hematology/Oncology, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton
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3
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The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question. Blood Adv 2022; 6:679-685. [PMID: 35072726 PMCID: PMC8791561 DOI: 10.1182/bloodadvances.2020003635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/24/2020] [Indexed: 11/20/2022] Open
Abstract
Choosing Wisely is a medical stewardship and quality-improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The American Society of Hematology (ASH) has been an active participant in the Choosing Wisely project. In 2019, ASH and the American Society of Pediatric Hematology/Oncology (ASPHO) formed a joint task force to solicit, evaluate, and select items for a pediatric-focused Choosing Wisely list. By using an iterative process and an evidence-based method, the ASH-ASPHO Task Force identified 5 hematologic tests and treatments that health care providers and patients should question because they are not supported by evidence, and/or they involve risks of medical and financial costs with low likelihood of benefit. The ASH-ASPHO Choosing Wisely recommendations are as follows: (1) avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding, (2) avoid platelet transfusion in asymptomatic children with a platelet count >10 × 103/μL unless an invasive procedure is planned, (3) avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history, (4) avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and (5) avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections. We recommend that health care providers carefully consider the anticipated risks and benefits of these identified tests and treatments before performing them.
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Connelly JA. Diagnosis and therapeutic decision-making for the neutropenic patient. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:492-503. [PMID: 34889413 PMCID: PMC8791128 DOI: 10.1182/hematology.2021000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- James A. Connelly
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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O'Brien SH, Badawy SM, Rotz SJ, Shah MD, Makarski J, Bercovitz RS, Hogan MJS, Luchtman-Jones L, Panepinto JA, Priola GM, Witmer CM, Wolfson JA, Yee M, Hicks LK. The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question. Pediatr Blood Cancer 2021; 68:e28967. [PMID: 34047047 DOI: 10.1002/pbc.28967] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Choosing Wisely is a medical stewardship and quality-improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The American Society of Hematology (ASH) has been an active participant in the Choosing Wisely project. In 2019, ASH and the American Society of Pediatric Hematology/Oncology (ASPHO) formed a joint task force to solicit, evaluate, and select items for a pediatric-focused Choosing Wisely list. By using an iterative process and an evidence-based method, the ASH-ASPHO Task Force identified 5 hematologic tests and treatments that health care providers and patients should question because they are not supported by evidence, and/or they involve risks of medical and financial costs with low likelihood of benefit. The ASH-ASPHO Choosing Wisely recommendations are as follows: (1) avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding, (2) avoid platelet transfusion in asymptomatic children with a platelet count 10 × 103 /μL unless an invasive procedure is planned, (3) avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history, (4) avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and (5) avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections. We recommend that health care providers carefully consider the anticipated risks and benefits of these identified tests and treatments before performing them.
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Key Words
- COAGULATION/coagulation, COAGULATION/venous thromboembolism prophylaxis, diagnosis, and treatment, PLATELETS/disorders of platelets, PHAGOCYTES/neutrophils, RED CELLS/anemia
- clinical: nutritional
- iron, cobalamin, folate, anemia, autoimmune neutropenia, iron deficiency, platelets, pre-operative coagulation, thrombophilia
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Mona D Shah
- Division of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Julie Makarski
- Independent consultant methodologist, Hamilton, ON, Canada
| | - Rachel S Bercovitz
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mary-Jane S Hogan
- Department of Pediatrics, Section of Hematology and Oncology, Yale School of Medicine, New Haven, CT
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Julie A Panepinto
- Division of Pediatric Hematology/Oncology, Children's Wisconsin/Medical College of Wisconsin, Milwaukee, WI
| | - Ginna M Priola
- Division of Pediatric Hematology/Oncology, Mission Children's Hospital, Asheville, NC
| | - Char M Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie A Wolfson
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama, Birmingham, AL
| | - Marianne Yee
- Division of Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, GA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lisa K Hicks
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
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Mörtberg A, Pütsep K, Höglund P. The blood protein hCAP-18 in neutropenia: An 18-month experience of a new ELISA for clinical use. Scand J Immunol 2021; 94:e13037. [PMID: 33662157 DOI: 10.1111/sji.13037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 12/18/2022]
Abstract
Neutropenia as an isolated clinical finding may include aetiologies ranging from severe disease to a transient condition, and differential diagnosis may be challenging. Previous data and clinical experience suggest that low levels of the neutrophil-derived protein human 18 kDa cathelicidin antimicrobial protein (hCAP-18) in the blood are predictive of more severe forms of neutropenia. The objective of this study was to present the results from a newly developed ELISA method that has been used in clinical routine in Sweden since 2018 for quantification of hCAP-18 in blood plasma. Using this method, we report that patients with severe disease analysed during the study period presented with low or undetectable levels of blood plasma hCAP-18, validating its use as screening tool for severe neutropenia. Furthermore, neutropenic patients as a group displayed lower levels of hCAP-18 as compared to blood donors. Within the group of neutropenic patients, those with neutrophil antibodies displayed significantly higher hCAP-18 levels compared to patients with idiopathic neutropenia. By including an analysis of hCAP-18 in the primary investigation of neutropenia, an increased accuracy in differential diagnosis is achieved, thus contributing to reduced costs of neutropenia management.
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Affiliation(s)
- Anette Mörtberg
- Medical Unit Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Katrin Pütsep
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Petter Höglund
- Medical Unit Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.,Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
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