New pulmonary infiltrates in granulocytopenic cancer patients being treated with antibiotics

Abstract

During a 5 1/2-year period, 34 of 829 episodes of granulocytopenia during which broad spectrum antibiotics were being administered for fever and/or infections were complicated by the development of new pulmonary infiltrates. In 12 patients the infiltrates were due to fungal pneumonia, while in 6 patients the infiltrates were due to a variety of other causes. In the remaining 16 cases the etiology of the infiltrates was not determined. Time to development of infiltrate, radiographic appearance of the infiltrate, patient temperature and absolute granulocyte count failed to predict the etiology of the infiltrate. Conversely, development of the infiltrate or its radiographic progression in the absence of bone marrow recovery correlated significantly with the diagnosis of fungal pneumonia. While empiric alterations of antibiotics at the time that the infiltrate appeared were not associated with improved survival, the early use of amphotericin B was associated with a significant decrease in fatal fungal pneumonia. We suggest that the diagnostic and therapeutic approach to the febrile, granulocytopenic patient who develops a new pulmonary infiltrate while receiving broad spectrum antibiotic therapy may be guided by the state of marrow recovery at the time of infiltrate appearance. Patients developing an infiltrate coincident with granulocyte recovery may be managed conservatively while patients whose infiltrate develops or progresses in the absence of granulocyte recovery should be considered to be at high risk for fungal pneumonia and if possible undergo a diagnostic lung biopsy and/or empiric antifungal therapy.