Limited Role of Sinus CT in the Management of Febrile Allogeneic Pediatric HSCT Recipients

With the absence of specific clinical practice guidelines for the management of febrile pediatric HSCT patients, many institutions apply oncology febrile neutropenia guidelines to pediatric HSCT patients.  Recent guidelines regarding the management of febrile neutropenia in pediatric oncology patients have questioned the role of sinus CT in their evaluation.  We sought to determine the predictive factors for positive findings on sinus CT and their impact on management of febrile pediatric allo-HSCT patients in the first year after transplant.  We conducted a retrospective chart review from 7/1/2007 through 6/30/13.  There were 41 febrile episodes from 37 patients that included sinus CT in the evaluation.  19 of the 41 episodes (46%) had positive findings on the sinus CT.  There was no statistically significant difference between the positive sinus CT and the negative sinus CT groups with regards to diagnosis, disease status, preparative regimen, HLA matching/graft source, GVHD, GVHD treatment, presence of NG or ETT, positive blood or urine culture, or positive findings on the pre-HSCT sinus CT.   The median time from onset of fever to the sinus CT in the positive sinus CT group and the negative sinus CT group was not significantly different using the log-rank test (256 hrs and 170 hrs, p= 0.14).  Median ANC and APC at onset of fever were significantly higher in the positive sinus CT group compared to the negative sinus CT group using the Wilcoxon rank sum test (2.470 10⁹/L and 3.050 10⁹/L versus 0.775 10⁹/L  and 1.060 10⁹/L , p= 0.03 and 0.04). 16% of episodes with a positive sinus CT had no other source of infection identified, but no episodes had changes to the pharmacotherapy regimen solely based on a positive sinus CT.  One patient did undergo bilateral endoscopic maxillary antrostomies and anterior ethmoidostomies, and cultures were positive for Candida glabrata.  Sinus CT has a minimal impact on the management of febrile pediatric allo-HSCT recipients and should be examined in larger multi-center groups to help develop practice guidelines.