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consistent with necrotic bowel. Serial abdominal x-rays should be performed to look
for intramural air (pneumatosis), which is a hallmark of this diagnosis, or free air,
which is an indication for surgery. A CT scan of the abdomen can be useful for
better delineation of the degree of bowel wall injury. If CT scan is unavailable,
ultrasound can show bowel wall thickening. Early surgical consultation is
appropriate. Surgery itself is reserved for uncontrollable coagulopathy or acidosis as
a consequence of bowel necrosis or evidence of perforation.
Treatment of confirmed or suspected C. difficile colitis should include empiric
vancomycin (oral) or metronidazole (parenteral or oral). Imaging is rarely useful,
except in the most severe cases.
As soon as characteristic vesicles on an erythematous base are seen, empiric
coverage for varicella should begin with acyclovir 10 mg/kg IV every 8 hours in
conjunction with appropriate hydration. The patient should be assessed for
pneumonitis with a careful respiratory examination, oxygen saturation, and a chest
radiograph. Liver enzymes should be measured for possible hepatic involvement.
All pediatric patients with fever and neutropenia less than 500 to 1,000 per μL
should be admitted to the hospital unless there is an institutional management
guideline that includes a specific follow-up plan for outpatient management of lowrisk fever and neutropenia. See the Children’s Hospital of Philadelphia Clinical
Pathway for Oncology Patient Presenting with Fever. In the case of sepsis or septic
shock, acute management as described in the Children’s Hospital of Philadelphia
Severe Sepsis Clinical Pathway 2 and Chapter 94 Infectious Diseases Emergencies
should be followed for oncology patients, with the empiric antibiotic coverage
described above for neutropenia. Stress-dose steroids should be considered in
patients who have received prolonged steroids recently either as part of cancer
treatment or management of nausea and vomiting.

COMPLICATIONS OF CAR-T CELL THERAPY
Goals of Treatment
Some patients with refractory or relapsed ALL or B-cell lymphoma may have
undergone treatment with chimeric antigen receptor modified T cells (CAR-T cell
therapy). This approach genetically modifies autologous T cells to express a

receptor which targets antigens on the surface of lymphoblasts. Though not currently
available in all centers, the early success of this therapy is likely to contribute to
more widespread use. Patients who have received CAR-T cell therapy are at risk for
serious and potentially fatal complications, including TLS, cytokine release
syndrome, and neurotoxicity.