Please register or login to view the chart

Neutropenia in primary care

Absolute neutrophil count ( ANC ) < 1.5 x 109 May suggest an underlying systemic or haematological disorder Increased risk of infections

Common incidental finding in primary care – often
○ drug induced
○ acute viral infection
 Agranulocytosis usually used to describe a more severe subset of neutropenia – count less than 0.2 
Carries risk of severe life threatening infections with susceptibility to opportunistic organisms
 Risk of infection is more severe when neutropenia is due to impaired production from chemotherapy or marrow failure
 Persons of African descent often have lower than normal neutrophil count

Decreased or ineffective production Accelerated turnover in blood Dislocation of shifts of cells from circulating to the marginal blood pools Unclear or combination of more than one mechanism ( eg thyroid dysfunction) .Rare for primary 
haematological malignancy to present with isolated neutropenia ( other cell 
lines are usually also 
affected )

Transient- Commonly associated with viral infections Eg EBV causing infectious mononucleosis is a very common cause ( see below ) Overwhelming bacterial infection can also deplete bone marrow reserves Chemotherapy agents Inflammatory and autoimmune conditions Drugs ( see below )

chronic- Less than 1.5 lasting > 3 months Can be a normal variant with people in good health- periodic FBC testing may indicate if 
○ any other haematological abnormality present
○ evidence underlying infection
○ inflammatory or malignant disease A count of < 0.5 – warrants an indepth evaluation Important to consider the condition when the sample was obtained
( count may vary considerably over short period of time , activity , exercise , eating etc )
○ take several measurements

Generally regarded as presence of a fever > 38° with an absolute neutrophil count of
 < 1.0 x 109

Result of bone marrow suppression- common SE of chemotherapy Risk of life threatening infections Most common complication of cancer chemotherapy Risk infection -consider in any systemically unwell patient receiving chemotherapy even if no fever present Risk increases with
○ age
○ advanced stage of disease
○ comorbidities
○ haematological malignancy
○ previous episode of febrile neutropenia
○ combined chemo-radiotherapy
○ poor nutritional status
○ Female 
○ Hb < 12
○ open wound or active infections
 Cases continue to be missed on initial presentation
○ not considered
○ patient may not disclose
○ lack of access to medical records
○ inability to mount an adequate inflammatory response – ie signs and symptoms may be minimal ( providing false reassurance ) Detailed history
○ nature of chemotherapy , which cancer
○ timing may give guidance on risk- although
 often unpredictable and should not be relied on
○ prior prophylactic antibiotics
○ concomitant steroid use 
( suppressed inflammatory response )
○ recent surgery Haematological malignancies can cause myelosuppression in patient even without chemotherapy

Presentation can be vague or with minimal symptoms
○ feeling hot or cold
○ rigors
○ sweats
○ flu like illness
○ general malaise Check for sore mouth and diarrhoea
 ( mucositis ) Do not wait for 
result of an urgent
 FBC – patients may decompensate 
rapidly Aim to determine how unwell the patient is Temp Signs of shock Focus of infection ( often not apparent ) If central line- check for signs of infection refer immediately- patients should 
receive IV antibiotics within 60 mins

Medical and family history ( heritable defects ) H/O recurrent infections Ask about oral inflammations
○ mouth ulcers
○ gingivitis
○ periodontitis
○ tooth loss , replacement Recurrent sinusitis and otitis Symptoms of pneumonia Perirectal pain and irritation

R/O Infection and Drug related causes Blood film Further tests- decide on individual basis Chronic viral serology Antinuclear antibodies and Rheumatoid factor Serum Immunoglobulin 
( Ig)Antineutrohil antibodies B12 , Folate , Iron , Ferritin TFT , LFT , HIV – if risk factors presentUs&Es if drug related -usually 
mild. -moderate decide on
 of risks/ benefit of treatment whether to continue the
 drug or not.- if continued 
carefully Severe cases of 
drug related neutropenia ie < 0.1 discontinue
 the drug

Suggestion of progressive or serious disease of any kind Bone marrow disorder suspected
○ eg anaemia and thrombocytopenia develops with pre-existing neutropenia Severe neutropenia with a downward trend in absolute neutrophil count Consistent neutropenia < 1.0



A complete resource for the patient from Lymphoma action

Cancer Net on neutropenia

CDC printable 2 page leaflet warning for chemotherapy patients

BC Cancer care page with a printable link on neutropenia

Understanding severe chronic neutropenia a 28 page document by Severe Chronic Neutropenia International Registry for patients – a good read for any clinician as well

Chronic neutropenia PIL from Indiana Hemophilia & Thrombosis Center



NICE guideline -Neutropenic sepsis:
prevention and management of neutropenic sepsis in cancer patients

ESMO clinical practice guideline on febrile neutropenia

Suspected Neutropenic Sepsis guideline from Wrightington, Wigan and Leight NHS Foundation Trust

Open access BMJ  article Forde CScullinChasing the Golden Hour – Lessons learned from improving initial neutropenic sepsis management. 

Benign Ethnic Neutropenia ( abstract )

Further reading on isolated chronic neutropenia Gupta A, Dhingra A. Incidental Chronic Neutropenia in an Asymptomatic Adult. Cureus. 2017;9(10):e1779. Published 2017 Oct 17. doi:10.7759/cureus.1779

A comprehensive article ” Evaluation and Management of Patients with Isolated Neutropenia “ Newburger PE, Dale DC. Evaluation and management of patients with isolated neutropenia. Semin Hematol. 2013;50(3):198–206. doi:10.1053/j.seminhematol.2013.06.010



  1. Newburger, Peter E, and David C Dale. “Evaluation and management of patients with isolated neutropenia.” Seminars in hematology vol. 50,3 (2013): 198-206. doi:10.1053/j.seminhematol.2013.06.010
  2. Neutropenia in primary care BMJ 2014 ;349:g5340
  3. Febrile neutropenia BMJ 2010 ;341 ; c6981
  4. Neutropenia Medscape Christopher D Braden et al Updated Aug 2017
  5. van Staa, T., Boulton, F., Cooper, C., Hagenbeek, A., Inskip, H. and Leufkens, H. (2003), Neutropenia and agranulocytosis in England and Wales: Incidence and risk factors. Am. J. Hematol., 72: 248-254. doi:10.1002/ajh.1029572:248 -254 ( 2003 )
  6. How We Evaluate and Treat Neutropenia in Adults : Outpatient Evaluation of Nuetropenia Medscape CME
  7. Lima, C.S.P., Paula, E.V., Takahashi, T. et al. Causes of incidental neutropenia in adulthood. Ann Hematol 85, 705–709 (2006).
  8. Essential Haematology-A. V Hoffbrand , P.A.H. Moss
  9. Oxford Handbook of Haematology – Reduced WBC Count
  10. Management of febrile neutropenia: ESMO Clinical Practice Guidelines de Naurois, J. et al. Annals of Oncology, Volume 21, v252 – v256
  11. Neutropenic Sepsis Prevention and Management of Neutropenic Sepsis in Cancer Patients st Velindre Cancer Centre Version 1.6 11.2014
  12. Neutropenic sepsis: prevention and management of neutropenic sepsis in
    cancer patients September 2012
    Developed for NICE by the National Collaborating Centre for Cancer



Related Charts:

Add Your Comments

Your email address will not be published.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

A4 Medicine  - Search Less and Learn More

Welcome to the A4 medicine community where we are constantly working to provide exceptional educational material to primary health care professionals. Subscribe to our website for complete access to our A4 Charts. They are aesthetically designed charts that contain 300 (plus and adding) common and complex medical conditions with the all information required for primary care in one single page that can help you in consultation/practice and exam.

Additionally, you will get complete access for our Learn From Experts : A4 Webinar Series in which domain experts share the video explainer presentation on one medical condition in one hour for the primary care. And you will also get a hefty discount on our publications and upcoming digital products.

We are giving a lifetime flat 30% discount to our first thousand users, discount code already applied to checkout.