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Febrile neutropenia and metabolic acidosis: case report A 7-year-old boy developed febrile neutropenia during treatment with venetoclax and cytarabine for acute myeloid leukaemia. He also developed metabolic acidosis during treatment with paracetamol for fever [not all dosages and routes not stated] The boy with relapsed/refractory acute myeloid leukaemia, started receiving treatment with venetoclax and cytarabine administered on days 1–28 and days 8–11, respectively, as a part of clinical trial. On day 22 of treatment, he developed febrile neutropenia related to the treatment and was hospitalised. He was additionally receiving micafungin, however, he tested positive for Candida krusei. Hence, treatment was changed to liposomal amphotericin B. His chemotherapy was held and he started receiving treatment with voriconazole day 5 of hospitalisation. He showed persistent fever and received treatment with oral paracetamol. On day 2 of hospitalisation, IV paracetamol [acetaminophen] 75 mg/kg/day every 4h was initiated. Laboratory findings showed increased levels of blood urea nitrogen and serum creatinine. Furthermore, a compensated high anion gap metabolic acidosis progressively developed. The boy was treated with continuous infusions of acetate, IV fluids and IV bicarbonate boluses, however, his metabolic acidosis worsened. Paracetamol was discontinued, and he was treated with fresh frozen plasma and phytonadione. On day 13, he received one standard loading dose of N-acetylcysteine 150 mg/kg. He concurrently developed acute heart failure with reduced ejection fraction (35%–40%) and cardiac dysrhythmias, requiring transfer to the ICU. Approximately 8 and 29h after discontinuation, the paracetamol concentrations obtained were below the lower limit of the reference range. However, urine 5-oxoproline concentration was increased. Upon admission to the ICU, his acidosis was treated with aggressive alkalization. He was initiated on total parenteral nutrition therapy. After improvement of fever, acidosis, and cardiac function, and achieving remission, he was shifted to another facility for further management and subsequently underwent haematopoietic cell transplantation without complications. Hoshitsuki K, et al. Metabolic Acidosis in a Pediatric Patient with Leukemia and Fungal Infection. Clinical Chemistry 66: 518-522, No. 4, Apr 2020. Available from: URL: 803519952 http://doi.org/10.1093/clinchem/hvz035

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Reactions 12 Dec 2020 No. 1834