Neutropenia, leukemia, and their influence on driving

Neutropenia

• Causes:
  • Reduction of neutrophil production due to birth defects, dysmyelopoiesis, bone marrow infiltration, marrow aplasia or hypoplasia, drugs or infections.
  • Ineffective production by megaloblastic anemia and drugs.
  • Abnormal distribution of neutrophils by hypersplenism or complement activation.
  • Reduction of neutrophil survival of autoimmune origin, or associated with rheumatoid arthritis and lupus systemic erythematosus.
• Common drugs associated with neutropenia:
  • Antibiotics such as chloramphenicol, penicillin, and derivatives, cephalosporins and sulfonamides.
  • Analgesics and antiinflammatories such as indomethacin, aminopyrine, dipyrone, and phenylbutazone.
  • Anticonvulsants such as diphenylhydantoin.
  • Antithyroids such as carbimazole, metimazole, and propylthiouracil.
  • Cardiovascular therapy such as captopril, methyldopa, propranolol, and quinidine.
  • Diuretics such as thiazides.
  • Neuroleptic such as phenothiazines and chlorpromazine.
• General care in the neutropenic patient:
  • In severe neutropenia, the risk of infections is very high and it is frequently serious for its association with bacteremia or sepsis.
  • The most significant neutropenia is that associated with tumors and particularly with its treatment with chemotherapy and radiation therapy.
  • Any patient with defense system disorders, whether congenital or acquired, is considered to be immunosuppressed.
  • In these patients, in addition to the common pathogens, opportunistic pathogens must be considered, that cannot usually overcome defensive barriers, but they do in this type of patients.
  • These patients are highly susceptible and require, with the least symptom of infection, study and hospital treatment until clinical stability is achieved, without metabolic complications or those derived from drug use, and verifying the good outcome of neutropenia.

Advice on Neutropenia

• These patients must know their risks and they should be advised against driving in the event of any infectious symptom.
• The possibility of a greater aggressiveness of the pathogens in these patients makes that, during the infectious conditions, they are recommended not to drive, until they achieve clinical stability without metabolic complications or those derived from the use of drugs, and verifying the good outcome of neutropenia.
• The specialist will report when the patient can safely drive again.

Leukemia

• Acute leukemia: The immature clonal cell cannot mature beyond the myeloblast or promyelocyte level in acute myeloid leukemia (AML), or the lymphoblast level in acute lymphoblastic leukemia (ALL). Bacterial and fungal infections, thrombocytopenia and spontaneous bleeding are frequent. Hepatosplenomegaly and lymphadenopathies are frequent in ALL. Leukemic meningitis can occur, associated with headache, nausea, seizures, and cranial pair paralysis. The treatment is based on individualized chemotherapy, with variable prognosis depending on the clinical case. If the outcome is favorable, maintenance chemotherapy can be prolonged for years. The added supportive treatment is based on transfusions of red blood cells, granulocytes, and platelets, as well as the prevention and treatment of infections. Bone marrow transplant is effective in acute leukemia. The complications are significant from graft vs host disease, interstitial pneumonitis and serious infections.
• Chronic leukemia: 
  • Chronic lymphatic leukemia (CLL) is a neoplasm characterized by accumulation in blood and bone marrow of lymphocytes of mature appearance, most frequently of type B. It can affect the lymph nodes and the spleen, and it can be complicated with hemolytic anemia, infections or progression to lymphoma. Many patients do not need treatment; in other patients, chemotherapy, corticoids and immunoglobulins will be prescribed by the specialized physician.
  • Chronic myeloid leukemia (CML) is frequently characterized by splenomegaly and granulocyte increase. In the beginning, there are few symptoms until the blastic crisis or leukemic phase is established, with cells of lymphoid or myeloid origin. The individualized treatment will be prescribed by the specialized physician, and the outcome is variable depending on the response to chemotherapy or bone marrow transplant in the adequate cases.
  • Tricholeukemia or leukemia of hair cells is a lymphoid neoplasm characterized by cytopenia, splenomegaly and proliferation of the so-called hair cells, almost always B, in blood and bone marrow. They are usually complicated with frequent infections and vasculitis, but their prognosis is good, since the patients usually respond well to the specific drugs in these cases.

Advice on Leukemia

• During the initial phases, with few symptoms, the patient can drive.
• Patients with severe neutropenia and aggressive infectious conditions should not drive.
• The tiredness and loss of attention caused by severe anemia or manifestations of the disease itself are disabling for driving.
• Bleeding does not permit driving until the bleeding site or the general coagulation disorder are controlled.
• The treatment with chemotherapeutic agents can provoke nausea, vomiting, and diarrhea that limit driving.
• Patients with neurological or psychiatric symptoms due to the disease itself or to the treatment applied should be advised against driving.