To the Editor,
Fever is a common complaint amongst children with an underlying
oncologic diagnosis, especially during chemotherapy course and periods
of neutropenia. It’s often necessitating presentation and
hospitalization for evaluation of sepsis. However, the cause(s) of the
fever is not usually clear [Lehrnbecher 2019]. Chemotherapy induced
fever is well described in relation to specific chemotherapy agents.
However, fever induced by vincristine (VCR) has only been rarely
reported [Ishii et al 1988 and Imai et al 2001], and the prevention
and management are not well established yet. We describe a case of
recurrent VCR-induced fever that was controlled with dexamethasone and
Tylenol.
Our patient is a 5-year-old female with stage III Wilms tumor who was
initiated on DD4A chemotherapy. She repeatedly developed fever within 24
hours after receiving chemotherapy from week 1 to 4 of treatment, where
she received VCR as a single agent or in combination with other agents.
As per institutional guidelines, the patient was hospitalized for
evaluation of underlying sepsis with each fever 4 weeks consecutively.
Fevers were high grade and lasting up to 48 hours. During fever
episodes, Her Absolute neutrophil count nadir was 700 K/CUMM (range
700-5000), and there were no other associated clinical symptoms, and
laboratory tests remained stable with normal white blood cell count and
differential, and negative septic work up and blood cultures.
Anticipating an underlying allergic reaction, we subsequently
prophylactically administered dexamethasone 3 mg/m2/dose IV along with
Acetaminophen 15mg/kg/dose PO one dose each prior and 12 hours after
Vincristine administration. Thereafter, the chemotherapy course
including weekly VCR was uneventful and there were no reported fevers.
The pathophysiology behind this phenomenon is not well established yet.
Imai et al suggested that an allergic response to VCR might be involved
when investigating recurrent fever in a 2 year old patient with
rhabdomyosarcoma after receiving VCR including chemotherapy. Leukocyte
migration testing (LMT) was performed which showed that migration index
with VCR added with the patient’s serum was significantly higher
compared to normal controls. These findings indicated the possibility of
an underlying delayed cell-mediated hypersensitivity to VCR.
Ishii et al reported that more than two VCR-induced fever episodes were
identified in 9 of 31 children with leukemia or lymphoma undergoing
maintenance chemotherapy. Similarly, they reported that the duration of
fever was shortened with corticosteroids suggesting the possibility of
an allergic reaction mechanism behind it.
Interestingly, this appears to be a rare phenomenon, given the wide
application of Vincristine in adult and pediatric chemotherapy protocols
and the scarcity of reports in the literature. A such, we hope to
support previous reports with our individual experience. In patients
developing recurrent fever following chemotherapy with VCR, febrile
allergic reaction and prophylactic treatment should be considered after
exhaustion of appropriate investigations.