What is the appropriate management for a patient with fever, neutrophilia, and normal platelet count?

Management of Fever with Neutrophilia (Not Neutropenia)

This patient does NOT have neutropenia—they have neutrophilia (82% neutrophils) with relative lymphopenia (9.6% lymphocytes), which represents a completely different clinical scenario that does not require the febrile neutropenia protocols described in oncology guidelines.

Critical Distinction

• The provided laboratory values show neutrophilia (elevated neutrophils at 82%, well above the normal 40-70% range), not neutropenia (absolute neutrophil count <0.5 × 10⁹/L) 1
• Normal platelet count further confirms this is not a hematologic malignancy or chemotherapy-related complication
• The relative lymphopenia (9.6%) with neutrophilia suggests an acute bacterial infection or inflammatory process, not immunosuppression

Appropriate Management Approach

For a patient with fever and neutrophilia, management should focus on identifying and treating the underlying infection or inflammatory condition causing the elevated neutrophil response:

Initial Assessment

• Identify the source of infection through focused history (respiratory symptoms, urinary symptoms, abdominal pain, skin infections, recent procedures)
• Physical examination targeting common infection sites: lungs, urinary tract, skin/soft tissue, abdomen, and indwelling catheters
• Obtain appropriate cultures (blood, urine, sputum if productive cough) before initiating antibiotics 2
• Chest radiograph if respiratory symptoms present 2

Antibiotic Management

• Initiate targeted antibiotic therapy based on the suspected source of infection, not broad-spectrum empiric coverage for neutropenic fever 3
• Adjust antibiotics based on culture results and clinical response
• Duration of therapy depends on the identified infection (typically 5-14 days for common bacterial infections)

Common Pitfalls to Avoid

• Do not apply febrile neutropenia protocols to patients with neutrophilia—this leads to unnecessary broad-spectrum antibiotics and hospitalization 1
• The fever with neutrophilia pattern typically indicates adequate immune response to infection, not immunocompromise requiring prophylactic antimicrobials 1
• Relative lymphopenia in acute bacterial infection is expected and does not indicate immunodeficiency requiring special precautions

When to Escalate Care

• Hemodynamic instability, hypotension, or signs of sepsis require immediate broad-spectrum coverage and intensive monitoring 4
• Failure to identify a source after thorough evaluation may warrant additional imaging or subspecialty consultation 2