Chapter 082. Infections in Patients with Cancer (Part 5)

Sweets syndrome, or febrile neutrophilic dermatosis, was originally described in women with elevated white blood cell (WBC) counts. The disease is characterized by the presence of leukocytes in the lower dermis, with edema of the papillary body. Ironically, this disease now is usually seen in neutropenic patients with cancer, most often in association with acute leukemia but also in association with a variety of other malignancies. Sweets syndrome usually presents as red or bluish-red papules or nodules that may coalesce and form sharply bordered plaques. The edema may suggest vesicles, but on palpation the lesions are solid, and vesicles...
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Chapter 082. Infections in Patients with Cancer (Part 5) Chapter 082. Infections in Patients with Cancer (Part 5) Sweets syndrome, or febrile neutrophilic dermatosis, was originallydescribed in women with elevated white blood cell (WBC) counts. The disease ischaracterized by the presence of leukocytes in the lower dermis, with edema of thepapillary body. Ironically, this disease now is usually seen in neutropenic patientswith cancer, most often in association with acute leukemia but also in associationwith a variety of other malignancies. Sweets syndrome usually presents as red orbluish-red papules or nodules that may coalesce and form sharply borderedplaques. The edema may suggest vesicles, but on palpation the lesions are solid,and vesicles probably never arise in this disease. The lesions are most common onthe face, neck, and arms. On the legs, they may be confused with erythemanodosum. The development of lesions is often accompanied by high fevers and anelevated erythrocyte sedimentation rate. Both the lesions and the temperatureelevation respond dramatically to glucocorticoid administration. Treatment beginswith high doses of glucocorticoids (60 mg/d of prednisone) followed by tapereddoses over the next 2–3 weeks. Data indicate that erythema multiforme with mucous membraneinvolvement is often associated with herpes simplex virus (HSV) infection and isdistinct from Stevens-Johnson syndrome, which is associated with drugs and tendsto have a more widespread distribution. Since cancer patients are bothimmunosuppressed (and therefore susceptible to herpes infections) and heavilytreated with drugs (and therefore subject to Stevens-Johnson syndrome), both ofthese conditions are common in this population. Cytokines, which are used as adjuvants or primary treatments for cancer,can themselves cause characteristic rashes, further complicating the differentialdiagnosis. This phenomenon is a particular problem in bone marrow transplantrecipients (Chap. 126), who, in addition to having the usual chemotherapy-,antibiotic-, and cytokine-induced rashes, are plagued by graft-versus-host disease. Catheter-Related Infections Because IV catheters are commonly used in cancer chemotherapy and areprone to infection (Chap. 125), they pose a major problem in the care of patientswith cancer. Some catheter-associated infections can be treated with antibiotics,while in others the catheter must be removed (Table 82-5). If the patient has atunneled catheter (which consists of an entrance site, a subcutaneous tunnel, andan exit site), a red streak over the subcutaneous part of the line (the tunnel) isgrounds for immediate removal of the catheter. Failure to remove catheters underthese circumstances may result in extensive cellulitis and tissue necrosis. Table 82-5 Approach to Catheter Infections in ImmunocompromisedPatients Clinical Catheter Antibiotics CommentsPresentation Removal Evidence of Infection, Negative Blood Cultures Exit-site Not necessary Usually begin Coagulase-erythema if infection responds treatment for gram- negative to treatment positive cocci. staphylococci are most common. Tunnel- Required Treat for gram- Failure tosite erythema positive cocci pending remove the culture results. catheter may lead to complications. Blood Culture–Positive Infections Coagulase Line removal Usually start If there are-negative optimal but may be with vancomycin. nostaphylococci unnecessary if (Linezolid, contraindications patient is clinically quinupristin/dalfopristi to line removal, stable and responds n, and daptomycin are this course of to antibiotics all appropriate.) action is optimal. If the line is removed, antibiotics may not be necessary. Other Recommende Treat with Thegram-positive d antibiotics to which the incidence ofcocci (e.g., organism is sensitive, metastaticStaphylococcus with duration based on infectionsaureus, the clinical setting. following S.Enterococcus); aureus infectiongram-positive and the difficultyrods (Bacillus, of treatingCorynebacterium enterococcalspp.) infection make line removal the recommended course of act ...