Case Presentation: A 74-year-old man with history of diffuse B cell lymphoma presented with 2 day history of fever, urinary frequency and dysuria, associated with poor oral intake, weakness and lightheadedness. He had completed the 6th and final cycle of chemotherapy with Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone, about 8 days prior to presentation. Vital signs on presentation were temperature of 38.9 celsius, pulse rate of 86, respiration of 20, blood pressure of 84/39, and oxygen saturation of 95% on room air. Physical examination showed a well-oriented elderly man without focal deficits. Air entry to lungs were equal bilaterally without crackles on auscultation. Heart sounds were normal, with regular rate and rhythm, and without peripheral edema. Abdomen was soft, without tenderness or organomegaly. Bowel sounds were normal. There was no skin rash, redness or ulcers.Complete blood count was significant for neutropenia with white blood cell count (WBC) of 0.3 x 10^3/uL (normal 3.7-9.6 x 10^3) and reduced absolute neutrophil count (ANC) of 300; low hemoglobin of 9.9 (normal 13.2-17.2) g/dL and platelet of 80 (normal 130-350) x 10^3/uL were also noted. Urinalysis with microscopy showed 5-9 urine red blood cells without urine WBC; urine nitrite and leucocyte esterase were negative. Chest x-ray was negative for acute infiltrates or other acute process.He was treated for neutropenic fever with sepsis from suspected urinary tract infection (UTI) with intravenous (IV) fluids and IV Tazobactam/Pipercillin empirically. Blood culture was negative but urine culture returned positive for Escherichia coli. Urinary symptoms, fever and hypotension resolved with treatment. Peripheral blood WBC improved to 2.8 x 10^3/uL and ANC improved to 2200. After a 3-day hospital stay, he was discharged in stable health on oral Amoxicillin/Clavulanate, to complete 10 days of treatment.
Discussion: Pyuria is the presence of increased number of polymorphonuclear leucocytes in urine (generally > 10 white blood cell/high power field). Its presence is often an important diagnostic clue to presence of a UTI, and its absence is a strong indicator that UTI is not present. Pyuria may however be absent in UTI in neutropenic patients. Despite the absence of pyuria in the case above, UTI was suspected as cause of sepsis in this patient with chemotherapy-induced neutropenia who presented with fever and urinary symptoms. Subsequent growth of Escherichia coli in urine culture confirmed the diagnosis.
Conclusions: In evaluating neutropenic fever, it is important to bear in mind that absence of pyuria does NOT rule out UTI in a neutropenic patient. Obtaining a urine culture may therefore be appropriate in neutropenic patients with (or without urinary symptoms but no other clear source of infection), even in the absence of pyuria.