known or not) when starting antibiotics and other medications that are renally
excreted.

GENITOURINARY COMPLICATIONS OF CANCER TREATMENT
The most common form of bladder injury in cancer patients is hemorrhagic cystitis,
a potential complication of exposure to cyclophosphamide or ifosfamide. Prevention
of drug-induced hematuria usually includes hydration, frequent voiding, and
administration of mesna (2-mercaptoethane sulfonate sodium), a drug that binds the
toxic metabolite. Manifestations include dysuria, suprapubic pain, and microscopic
or gross hematuria with onset within 24 hours of drug administration. Other causes
of toxicity to the GU tract include infection, bladder radiation, tumor resection, or
ongoing presence of tumor in the GU tract.
If a patient is complaining of bladder-related symptoms or the urinalysis shows
evidence of hematuria, the oncology-specific history should be reviewed to help
develop an appropriate differential diagnosis in addition to the usual causes (such as
infection) that would be considered in a patient without cancer. Initial management
should include initiation of one and one-half times to twice maintenance hydration
and frequent voiding. Laboratory evaluation should include a urinalysis, CBC to
look for anemia or thrombocytopenia, and coagulation studies. Any contribution
from coagulopathy and/or thrombocytopenia should be corrected. If severe bleeding
or bladder outlet obstruction from clots occurs, a urologist should be consulted. A
bladder catheter large enough to be used for irrigation should be placed and bladder
washing initiated. Packed red blood cell transfusion may be needed. In very rare
cases, bleeding can be life threatening and bladder sclerosis is indicated. Mesna has
no utility once the offending drug has cleared from the system. Pain management
with oxybutynin chloride and narcotics should be initiated as needed.

SKIN COMPLICATIONS OF CANCER TREATMENT
Various cancer treatments are known to have cutaneous toxicities. Radiation induces
dermatitis in the treatment field that can range from mild to severe based on the total
dose and any concurrent radiation sensitizers. The presentation may vary from a

mild erythroderma, similar to sunburn, to severe desquamation in the treatment
field. Any topical treatment must be prescribed in conjunction with the treating
radiation oncologist because certain topical agents may increase the radiation dose
to the skin.
Drug rashes are very common in oncology patients. Because patients tend to be
on many drugs at one time, it may be difficult to identify the specific culprit.
Management of a drug reaction is not unique in oncology patients. However,
consultation with the oncologist may be needed to discuss if alternate treatment is
needed.


Infections may be accompanied by cutaneous manifestations (see Chapter 94
Infectious Disease Emergencies ). Although not unique to oncology patients, certain
infections affecting the skin may be more common in this patient group.
Immunosuppressed patients are at increased risk for herpes simplex and herpes
zoster. Any skin lesions in a dermatomal distribution, with or without associated
pain and whether or not the lesions are “classic,” should be considered herpes zoster
until proven otherwise. Immunocompromised patients with herpes zoster have an
increased risk of disseminated disease and should be placed in respiratory isolation.
Evaluation should include chest radiograph and liver function tests. If there is a
vesicular lesion, it should be scraped and sent for both rapid testing (e.g., PCR) and
culture for herpes simplex and varicella zoster. Empiric therapy should be started
with either acyclovir or one of its derivatives. Admission for intravenous therapy is
indicated in patients in whom there is evidence of dissemination, ophthalmologic
involvement, or failure to respond to oral therapy. Oral home therapy can be
considered in consultation with the oncologist after considering extent of
involvement, degree of underlying immunosuppression, likelihood of medication
compliance at home, and ability to follow up.

COMPLICATIONS OF HEMATOPOIETIC STEM CELL

TRANSPLANTATION
Bone marrow transplantation is increasingly utilized in the treatment of various
hematologic, oncologic, metabolic, or immunologic diseases. In hematologic
malignancies, allogeneic marrow transplantation may follow initial remission,
induction, or disease relapse. The allogeneic donor may be related, usually a sibling,
or unrelated to the recipient. In solid tumors and some lymphomas, patients may
receive aggressive chemotherapy and radiation and then have their own stem cells
infused as a “rescue” to help reconstitute their immune system following therapy
(autologous transplant). Knowledge of the type of transplant a patient received (
Table 98.11 ) can help the clinician anticipate what complications might ensue. In
general, stem cell transplant recipients represent a fragile patient population at risk
for many complications.
In approaching these patients, substantial immunosuppression should be
presumed for at least 6 months following the transplant. For patients still receiving
immunosuppressing medications, the period of immune dysfunction may be much
longer. Regardless of the WBC and neutrophil counts, immune function following a
stem cell transplant can be profoundly impaired.
Graft-versus-host disease (GVHD) may develop in the setting of allogeneic stem
cell transplants as newly engrafted immune cells of the donor react against tissue
antigens of the recipient that are perceived to be foreign ( Table 98.11 ). Acute
GVHD occurs in the first 100 days posttransplant, often when patient is still in


hospital, and typically involves the skin, GI tract, or liver. Chronic GVHD presents
after 100 days and is accompanied by severe immunologic dysfunction.
The evaluation of patients with known or suspected GVHD following an
allogeneic stem cell transplant should include assessment of potential dehydration or
anemia due to colitis or dyspnea due to lung involvement. Physical examination
should assess the skin for rash, fibrosis, or jaundice, liver size and tenderness, and
oxygen saturation, with a focus on screening for organ dysfunction serious enough

to require intervention in the ED. Clinicians should have a low threshold for
admitting such patients for inpatient management due to overall fragility of this
patient population.
Therapy for GVHD is primarily immunosuppressive using corticosteroids,
cyclosporine, and other agents directed against T cells. Specialists in hematopoietic
stem cell transplant decide whether to pursue such agents and when. Often a biopsy
(skin, bowel, liver, etc.) is required to diagnose GVHD on histopathology.
The management of infectious complications for patients following stem cell
transplant is not inherently different from the oncology population overall, but the
relevant organisms may vary and the clinician’s level of suspicion may need to be
higher ( Table 98.11 ). Infections in these patients result from the extreme
immunosuppression achieved by myeloablation, cutaneous and mucosal barrier
damage intrinsic to the transplant process, and the immunologic immaturity of the
transplanted marrow. Central lines exacerbate this risk.
Importantly, the types of infections patients tend to develop after hematopoietic
stem cell transplant can vary based on how many days have elapsed since the
transplant.
In the first month after the transplant, as patients are hospitalized and awaiting
engraftment of their bone marrow, they are vulnerable to gram-positive and gramnegative bacteria, anaerobic bacteria, respiratory viruses, reactivation of herpes
simplex virus, and fungal infection with candida and aspergillus.
After engraftment, from day 30 to 100 after the transplant, patients remain at risk
for bacterial infections, particularly those related to their central lines. Aspergillus
and respiratory viruses continue to be a concern. However, CMV, pneumocystis,
and toxoplasma become more of a threat at this point.
More than 100 days after the transplant, patients are at risk for encapsulated
bacteria, especially if they are simultaneously affected by GVHD or ongoing
immunosuppression. Aspergillus, pneumocystis, and toxoplasma continue to be a
concern. Viral infections with varicella zoster virus, CMV, EBV, and respiratory
viruses are also a large threat for these patients.
When patients present to the ED with fever following a hematopoietic stem cell

transplant, empiric coverage with antibiotics should be instituted quickly while


cultures of the blood and urine are pending. While gram-negative organisms have
historically been of primary concern, gram-positive bacteria have more recently
become more threatening, particularly with the emergence of MRSA in some
regions. Antibiotic regimens need to broadly cover gram-positive and gram-negative
bacteria (e.g., piperacillin/tazobactam and gentamicin) as well as MRSA when
relevant.
Rarely seen as a complication of stem cell transplant, thrombotic
thrombocytopenic purpura (TTP) can present with the classic pentad of fever,
neurologic symptoms, hemolytic anemia, thrombocytopenia, and renal compromise
( Table 98.11 ). The disorder seems to be associated with immunosuppression with
cyclosporine or FK506 in the posttransplant period. In some patients, TTP may
evolve into a more chronic picture with renal dysfunction and a clinical picture more
consistent with HUS.
An experimental, promising new treatment for leukemia involves chimeric
antigen receptor modified T cells (CART). See Complications of CAR-T Cell
Therapy section above. In this specialized therapy, a patient’s T cells are harvested
and engineered to express a receptor that allows them to seek out and destroy
leukemic blasts. These cells are then reinfused into the patient in an inpatient setting.
Importantly for emergency clinicians, steroids are contraindicated for any patients
being treated with CART therapy since steroids are lymphotoxic and likely to be
detrimental to this type of therapy.

CARE OF PATIENTS WITH ADVANCED CANCER
Pediatric palliative care has seen major changes in recent decades and these
developments clearly impact care for children with cancer. Children with incurable
cancer may still receive treatment that may be life prolonging and options for
managing symptoms related to advanced disease have expanded. Also noteworthy is

the increased decision-making role for the patient and family members in the setting
of advanced disease. Options for patients to receive care outside of the hospital,
either in hospice or at home, have greatly evolved.