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Left common carotid artery vasculitis and grade 4 febrile neutropenia: case report A 66-year-old woman developed left common carotid artery vasculitis during treatment with pegfilgrastim and grade 4 febrile neutropenia secondary to cyclophosphamide and doxorubicin treatment for metastatic breast cancer [not all dosages stated; routes and times to reaction onsets not stated]. The woman, who was diagnosed with cancer of the left breast, underwent total mastectomy with axillary lymph node dissection in August 2019. She was scheduled to receive adjuvant chemotherapy consisting of four cycles of tri-weekly doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 (AC) followed by 12 cycles of weekly paclitaxel 80 mg/m2. Four weeks after surgery, she received the first cycle of AC, and pegfilgrastim [peg-G; granulocyte colony stimulating factor (G-CSF)] was prophylactically administered on day 3. On day 14, she presented to a hospital with fever (38.8°C) and left anterior neck pain. Laboratory examination revealed the following: WBC count 11.6 × 103 /µL, absolute neutrophil count 9.8 × 103 /µL and C-reactive protein (CRP) 8.24 mg/dL. A CT scan showed low attenuation wall thickening of the left common carotid artery (not observed before surgery). She then started receiving series of unspecified antibiotics for 6 days on suspicion of an infection. However, her symptoms did not improve and her CRP level elevated to 12.34 mg/dL. At this point, the possibility of G-CSF-associated vasculitis was considered. On day 20, additional blood tests and bacterial cultures were performed to rule out other vasculitis syndromes or infections. It revealed the following: elevated ESR 117 mm/h, negative rheumatoid factor, negative antinuclear antibody, negative myeloperoxidase antineutrophil cytoplasmic antibody (ANCA) and negative proteinase-3 ANCA. Viral markers for hepatitis C and hepatitis B were both negative. The procalcitonin concentration was less than 0.02 ng/mL. Urine and blood cultures were negative. Based on above-mentioned results, she was diagnosed with pegfilgrastim-associated vasculitis. Following negative cultures, the woman’s therapy with unspecified antibiotics were discontinued, and she received loxoprofen. Within 3 weeks, her symptoms spontaneously disappeared, and her blood inflammatory markers normalised 23 days after onset of symptoms. Six weeks after the first AC, she received the second cycle of the chemotherapy without prophylactic use of pegfilgrastim. On day 14 of this second AC, she developed grade 4 (according to CTCAE v 5.0) neutropenia (with fever)* . Fever was not observed during the subsequent adjuvant chemotherapy. She completed the scheduled four cycles of AC. It was suspected that the febrile neutropenia was caused by AC regimen comprising cyclophosphamide and doxorubicin. The Naranjo’s algorithm score was 6, indicated a ’probable’ association between pegfilgrastim and vasculitis. * Initial event was considered as Febrile neutropenia as subsequent cycles were without fever. Nakamura J, et al. Pegfilgrasti