A Practical Algorithm for the Evaluation of Patients with Neutropenia - Flowchart
A Practical Algorithm for the Evaluation of Patients with Neutropenia - Flowchart Complete Blood Count (CBC) Complete Blood Count (CBC)
«Flowchart»

START

START

START

Hospitalize, obtain cultures, and consider empiric antibiotic Rx

Hospitalize, obtain cultures, and consider empiric antibiotic Rx

Hospitalize, obtain cultures, and consider empiric antibiotic Rx

Examine peripheral blood smear and check MCV

Examine peripheral blood smear and check MCV

Examine peripheral blood smear and check MCV

Bi- or pancytopenia

Bi- or pancytopenia

Bi- or pancytopenia

Selective neutropenia?

Selective neutropenia?

Selective neutropenia?

Yes

Yes

Yes

No

No

No

Discontinue suspect drug. Response?

Discontinue suspect drug. Response?

Discontinue suspect drug. Response?

Taking drugs?

Taking drugs?

Taking drugs?

Yes

Yes

Yes

No

No

No

No

No

No

History of recurrent infections?

History of recurrent infections?

History of recurrent infections?

Yes

Yes

Yes

No

No

No


Aplastic anemia
AIDS
Drug-related


Toxic
Immunologically mediated


Immune injury


Cytotoxic T cells (T)
Antibody-mediated (Ab)
Both T and Ab


Toxin-mediated injury
Certain viral infections
Mycobacterial infections
Myelodysplasia
Paroxysmal nocturnal hemoglobinuria
Hereditary neutropenia syndromes


Aplastic anemia
AIDS
Drug-related


Toxic
Immunologically mediated


Immune injury


Cytotoxic T cells (T)
Antibody-mediated (Ab)
Both T and Ab


Toxin-mediated injury
Certain viral infections
Mycobacterial infections
Myelodysplasia
Paroxysmal nocturnal hemoglobinuria
Hereditary neutropenia syndromes


Aplastic anemia
AIDS
Drug-related


Toxic
Immunologically mediated


Immune injury


Cytotoxic T cells (T)
Antibody-mediated (Ab)
Both T and Ab


Toxin-mediated injury
Certain viral infections
Mycobacterial infections
Myelodysplasia
Paroxysmal nocturnal hemoglobinuria
Hereditary neutropenia syndromes


Aplastic anemia
AIDS
Drug-related


Toxic
Immunologically mediated


Toxic
Immunologically mediated
Immune injury


Cytotoxic T cells (T)
Antibody-mediated (Ab)
Both T and Ab


Cytotoxic T cells (T)
Antibody-mediated (Ab)
Both T and Ab
Toxin-mediated injury
Certain viral infections
Mycobacterial infections
Myelodysplasia
Paroxysmal nocturnal hemoglobinuria
Hereditary neutropenia syndromes

Bone marrow examination

Bone marrow examination

Bone marrow examination

Hypocellular

Hypocellular

Hypocellular

Normal or increased cellularity

Normal or increased cellularity

Normal or increased cellularity

End

End

End

Familial neutropenia

Familial neutropenia

Familial neutropenia

Family history of chronic neutropenia?

Family history of chronic neutropenia?

Family history of chronic neutropenia?

Yes

Yes

Yes

No

No

No

Idiopathic, congenital, pseudoneutropenia

Idiopathic, congenital, pseudoneutropenia

Idiopathic, congenital, pseudoneutropenia

Chronic inflammatory or autoimmune disease?

Chronic inflammatory or autoimmune disease?

Chronic inflammatory or autoimmune disease?

Yes

Yes

Yes

No

No

No


Neutrophil destruction
Neutrophil utilization


Infection
Trauma


Sequestration
Tissue necrosis
Hypersplenism


Neutrophil destruction
Neutrophil utilization


Infection
Trauma


Sequestration
Tissue necrosis
Hypersplenism


Neutrophil destruction
Neutrophil utilization


Infection
Trauma


Sequestration
Tissue necrosis
Hypersplenism


Neutrophil destruction
Neutrophil utilization


Infection
Trauma


Infection
Trauma
Sequestration
Tissue necrosis
Hypersplenism


Acute leukemia
Myelodysplasia
Lymphoma
Hairy cell leukemia
AIDS
Carcinoma
Fibrosis
Immune injury
Megaloblastic (B12/folate deficiency)


Acute leukemia
Myelodysplasia
Lymphoma
Hairy cell leukemia
AIDS
Carcinoma
Fibrosis
Immune injury
Megaloblastic (B12/folate deficiency)


Acute leukemia
Myelodysplasia
Lymphoma
Hairy cell leukemia
AIDS
Carcinoma
Fibrosis
Immune injury
Megaloblastic (B12/folate deficiency)


Acute leukemia
Myelodysplasia
Lymphoma
Hairy cell leukemia
AIDS
Carcinoma
Fibrosis
Immune injury
Megaloblastic (B12/folate deficiency) 12

Normal morphology?

Normal morphology?

Normal morphology?

Yes

Yes

Yes

No

No

No

Oval macrocytes or high MCV?

Oval macrocytes or high MCV?

Oval macrocytes or high MCV?

Yes

Yes

Yes

No

No

No

B12/folate deficiency

B12/folate deficiency

B12/folate deficiency

12

Obtain serum B12 and folate levels. Low?

Obtain serum B12 and folate levels. Low?

Obtain serum B12 and folate levels. Low?

12

Yes

Yes

Yes

No

No

No

Hypersegmented neutrophils?

Hypersegmented neutrophils?

Hypersegmented neutrophils?

Yes

Yes

Yes

No

No

No

Reconsider B12/folate deficiency. Order RBC folate, methylmalonate, homocysteine. Abnormal?

Reconsider B12/folate deficiency. Order RBC folate, methylmalonate, homocysteine. Abnormal?

Reconsider B12/folate deficiency. Order RBC folate, methylmalonate, homocysteine. Abnormal?

12

Yes

Yes

Yes

No

No

No

Discontinue.
Response?

Discontinue.
Response?

Discontinue.
Response?


Toxins? Drugs?

Toxins? Drugs?

Toxins? Drugs?

Yes

Yes

Yes

No

No

No

No

No

No

Complete blood count with differential and platelet count

Complete blood count with differential and platelet count

Complete blood count with differential and platelet count

Neutrophil count
<1 × 109/L

Neutrophil count
<1 × 109/L


9 Neutrophil count <1 × 10[9]/L

Neutrophil count
<2 × 109/L >1 × 109/L

Neutrophil count
<2 × 109/L >1 × 109/L


9 9 Neutrophil count <2 × 10[9]/L >1 × 10[9]/L

Fever (>38� C [100.4� F]) or signs of infection?

Fever (>38� C [100.4� F]) or signs of infection?

Fever (>38� C [100.4� F]) or signs of infection?

Yes

Yes

Yes

No

No

No

Toxin exposure?

Toxin exposure?

Toxin exposure?

Stop exposure

Stop exposure

Stop exposure

No

No

No