Neutropenia & Low White Blood Cell Counts Guide

Neutrophils are the white blood cells that do most of the work of fighting infection. The National Cancer Institute defines neutropenia as "a condition in which there is a low number of neutrophils." Chemotherapy and some cancers lower that number.

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A fever of 100.4 °F (38 °C) or higher during chemotherapy, or any time your team has told you your white count is low, is a sign of infection. Call your team right away, at any hour.

NCI states: "Call your health care team if you have signs of an infection. Infections during cancer treatment can be life threatening and require urgent medical attention."

During chemotherapy, or any time your team has told you your white count is low, a temperature of 100.4 °F (38 °C) or higher means calling your care team right away, at any hour. One reading is enough. Do not wait an hour or check again first. CDC says to call your doctor immediately at that number and calls a fever during chemotherapy a medical emergency (CDC). It also says to know which number to call when the office is closed. If your team gave you a lower number, use theirs. Read the number as written. Not 100 degrees, not "about 101," not "if it stays up." If you are unsure, call anyway. No oncology service minds being called about a fever.

If you are on chemotherapy, or your team has told you your white count is low, call your team right away, at any hour, for chills, a new or changed cough, a sore throat or new mouth sore, diarrhea, pain when you urinate, a stiff neck, or redness or swelling where a catheter enters your body. These are on CDC's list of signs to call about right away (CDC).

A normal temperature is not permission to wait. If you are having chemotherapy, or your white blood cell count is low, call your care team right away, day or night, for chills, a sore throat, mouth sores, burning when you urinate, redness or swelling around a catheter, or any other sign of infection. You do not need a fever first.

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This is the step people get wrong out of good intentions. NCI warns: "Be sure to talk with your doctor or nurse before taking medicine—even aspirin, acetaminophen (such as Tylenol®), or ibuprofen (such as Advil®) for a fever. These medicines can lower a fever but may also mask or hide signs of a more serious problem."

Bringing the number down does not treat the infection. It hides the signal your team needs.

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Alongside fever, NCI lists:

• chills
• cough or sore throat
• diarrhea
• ear pain, headache or sinus pain, or a stiff or sore neck
• skin rash
• sores or white coating in your mouth or on your tongue
• swelling or redness, especially where a catheter enters your body
• urine that is bloody or cloudy, or pain when you urinate

The American Cancer Society adds fast heartbeat, breathing problems, dizziness or lightheadedness, and joint or bone pain.

An important caveat: ACS says that in people with low white blood cells, fever may often be the first and sometimes only sign of infection.

When to get help

• Call 911 or go to the nearest emergency department if you are suddenly confused or hard to wake, have trouble breathing even at rest, or have chest pain. ACS lists new or worsening confusion, chest pain and trouble breathing as reasons to get medical help.
• Call your care team right away, day or night, if you have a temperature of 100.4 °F (38 °C) or higher, chills, a sore throat, mouth sores, burning when you urinate, redness or swelling around a catheter, or any other sign of infection listed above. Tell them you are having chemotherapy.

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NCI explains that some cancers and treatments such as chemotherapy raise infection risk because they lower white blood cell numbers: "During chemotherapy, there will be times in your treatment cycle when the number of white blood cells (called neutrophils) is particularly low and you are at increased risk of infection." NCI adds that stress, poor nutrition, and not enough sleep can also weaken the immune system.

Ask your team when in your cycle your count is expected to be lowest — that is the window to be most careful in.

NCI notes that "medicine may sometimes be given to help prevent infection or to increase the number of white blood cells." ACS describes these as growth factors, "also called granulocyte colony-stimulating factors (G-CSFs)," usually given as a shot.

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NCI's prevention advice:

Wash your hands often and well. Use soap and warm water, especially before eating. Have people around you wash their hands well too.

Stay extra clean. If you have a catheter, keep the area around it clean and dry. Clean your teeth well and check your mouth for sores each day. Clean any scrape or cut well. Tell your doctor or nurse if your bottom is sore or bleeds, as this could increase your risk of infection.

Avoid germs. Stay away from people who are sick or have a cold. Avoid crowds, and people who have just had a live vaccine such as one for chicken pox, polio, or measles.

Handle food safely. Make sure meat, fish, and eggs are well cooked. You may be advised to eat only fruits and vegetables that can be peeled, or to wash all raw fruits and vegetables very well.

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NCI suggests bringing these to your visit:

• Am I at increased risk of infection during treatment? When am I at increased risk?
• What steps should I take to prevent infection?
• What signs of infection should I look for?
• Which signs signal that I need urgent medical care at the emergency room? Which should I call you about?

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• National Cancer Institute: Infection and Neutropenia during Cancer Treatment. https://www.cancer.gov/about-cancer/treatment/side-effects/infection
• American Cancer Society: What to Do for Low White Blood Cell Counts. https://www.cancer.org/content/dam/cancer-org/cancer-control/en/what-to-do/what-to-do-for-low-white-blood-cell-counts.pdf
• American Cancer Society: Low White Blood Cell Counts (Neutropenia). https://www.cancer.org/cancer/managing-cancer/side-effects/low-blood-counts/neutropenia.html
• American Cancer Society: Fevers. https://www.cancer.org/cancer/managing-cancer/side-effects/infections/fever.html
• MedlinePlus (National Library of Medicine): Cancer treatment - preventing infection. https://medlineplus.gov/ency/patientinstructions/000913.htm
• CDC: Fever and chemotherapy. https://www.cdc.gov/cancer-preventing-infections/patients/fever.html