Cefepime induced bone marrow suppression in a child with osteomyelitis.

Cefepime, a fourth generation cephalosporin is known to cause headaches (2.4%), nausea (1.8%), rash (1.8%) and diarrhea (1.7%). Cefepime is not known to cause neutropenia and is indicated as monotherapy for empiric treatment of febrile neutropenic patients. After an exhaustive search of the medical literature and discussion with cefepime's sole manufacturers, we report the first case of cefepime induced bone marrow suppression. A 4-year-old white male was admitted with 5 days of intermittent fevers with a T max 105.4[degrees]F. His history included hospitalization for 8 days, a month before for low grade fevers and left groin pain. After an extensive workup, he was diagnosed to have osteomyelitis of L5 disc and pelvic ramus. His medications included ibuprofen and Lortab for pain and intravenous nafcillin for 3 days. He was discharged on a course of oral azithromycin for 5 days and intravenous cefepime for 1 month. His CBC a week after discharge was WBC 6.3 K/cmm; Hgb 11.3 g/dl; Hct 33%; MCV 83 cmic; Plt 378 K/cmm. Examination revealed an active child with an unremarkable physical examination except for mild limited range of motion of his left hip. Current admission investigations: WBC 2.6 K/cmm; ANC 26; Hgb 10 g/dl; Hct 29.3%; MCV 76.4 cmic; Plt 144 K/cmm. Peripheral blood: Severe neutropenia, normoblastic anemia with reticulocytopenia and mild thrombocytopenia. Bone marrow studies: Hypocellular marrow with myeloid hypoplasia with no phenotypic evidence of abnormal lymphoid or blast population. Course in hospital: Cefepime was discontinued and vancomycin started. A single dose of subcutaneous filgrastim (G-CSF) improved his CBC; WBC 4.1 K/cmm; ANC 700. He was discharged on vancomycin with his CBC showing WBC 5.5 K/cmm; ANC 1595, 1 week later. Cefepime induced bone marrow suppression is a possibility that resolves with its discontinuation and responds to G-CSF.

Jaideep Shenoi, MD, and B. Bhushan Sharma, MD. Department of Medicine-Pediatrics and Department of Pediatrics, University of Oklahoma-College of Medicine, Tulsa, OK.