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Wilkerson RG. Drug Hypersensitivity Reactions. Immunol Allergy Clin North Am 2023; 43:473-489. [PMID: 37394254 DOI: 10.1016/j.iac.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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2
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Gangadaran V, Balasubramanian M. Significance of Oral Manifestations in the Diagnosis of Severe Phenytoin-Induced Thrombocytopenia: A Rare Case. Cureus 2023; 15:e37585. [PMID: 37069839 PMCID: PMC10105007 DOI: 10.7759/cureus.37585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 04/19/2023] Open
Abstract
Phenytoin is a commonly used anticonvulsant drug for the prophylaxis of generalized tonic-clonic seizures, partial seizures, and neurosurgery-related seizure prevention. Phenytoin-induced thrombocytopenia is a rare but life-threatening condition. Close monitoring of blood counts may be necessary for patients receiving phenytoin, as delay in diagnosis or withdrawal of the drug can be life-threatening. Clinical manifestations of phenytoin-induced thrombocytopenia are usually reported within one to three weeks after drug initiation. In this article, we report a unique case of drug-induced thrombocytopenia that manifested as multiple hemorrhagic lesions in the oral mucous membrane three months after phenytoin initiation.
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Affiliation(s)
- Vinodh Gangadaran
- Department of Dentistry, Kilpauk Medical College and Hospital, Chennai, IND
| | - Manonmani Balasubramanian
- Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College and Hospital, Chennai, IND
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3
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Abu-Abaa M, Jumaah O, Chadalawada S, Kananeh S, Gugnani M. The Clinical Challenge of Refractory Octreotide-Induced Thrombocytopenia in Active Gastrointestinal Bleeding: A Case Report. Cureus 2023; 15:e34590. [PMID: 36874323 PMCID: PMC9981475 DOI: 10.7759/cureus.34590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 02/05/2023] Open
Abstract
The association between octreotide and thrombocytopenia has been documented in the literature but it remains a rare finding. We are reporting a 59-year-old female patient with alcoholic liver cirrhosis who presented with the gastrointestinal tract (GIT) bleeding secondary to esophageal varices. Initial management involved fluid and blood products resuscitation and initiation of both octreotide and pantoprazole infusion. However, the abrupt onset of severe thrombocytopenia was evident within a few hours of admission. Platelet transfusion and discontinuation of pantoprazole infusion failed to correct the abnormality prompting the holding off of octreotide. However, this also failed to control the decline in platelet count and prompted intravenous immunoglobulin (IVIG). This case helps to remind clinicians to closely monitor platelet count once octreotide is initiated. This allows early detection of the rare entity of octreotide-induced thrombocytopenia, which can be life-threatening with extremely low platelet count nadir.
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Affiliation(s)
- Mohammad Abu-Abaa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Omar Jumaah
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | | | - Salman Kananeh
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Manish Gugnani
- Pulmonary and Critical Care Medicine, Capital Health Regional Medical Center, Trenton, USA
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4
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Park CL, Margaria B, Husnain M. Secondary Immune Thrombocytopenia Due to Mycoplasma pneumoniae Without Clinically Significant Evidence of Active Infection. Cureus 2022; 14:e23551. [PMID: 35494983 PMCID: PMC9042787 DOI: 10.7759/cureus.23551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/06/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a leading cause of isolated thrombocytopenia characterized by autoantibody-mediated destruction of platelets, impaired megakaryocyte function, and pathologic T-cell recognition of platelet antigens. Several triggers for ITP have been identified. Treatment of the inciting cause decreases the antibodies responsible for molecular mimicry, and these cases are usually associated with a better outcome with a decreased probability of progression to chronic ITP. Mycoplasma pneumoniae infection is known to have extrapulmonary manifestations, and growing evidence suggests it can be a cause of secondary ITP. Many of the described cases report evidence of a pulmonary infection with severe mucosal bleeding. Here, we describe an interesting case of a patient presenting with isolated thrombocytopenia with mild mucosal bleeding, later found to be positive for Mycoplasma immunoglobulin M without clinically significant evidence of active infection. Currently, mycoplasma testing is not routinely performed as a workup for ITP. However, clinicians may consider this before proceeding with more aggressive treatment for refractory ITP (i.e., prolonged immunosuppression, splenectomy). This case illustrates that mild/asymptomatic Mycoplasma infection can also be associated with ITP.
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5
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Lægreid IJ, Olsen MI, Harr JI, Grønli RH, Mørtberg TV, Ernstsen SL, Ahlen MT. Acute drug-induced immune thrombocytopenia - A work of articaine. Transfusion 2022; 62:1142-1147. [PMID: 35305268 PMCID: PMC9314149 DOI: 10.1111/trf.16858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 12/01/2022]
Abstract
Background Drug‐induced immune thrombocytopenia (DITP) is a rare, but serious complication to a wide range of medications. Upon suspicion, one should do a thorough clinical evaluation following proposed diagnostic criteria and seek laboratory confirmation. If confirmed, it is important to ensure avoidance of the drug in the future. Study design and methods Herein, we describe a young adult male who experienced two bouts of severe thrombocytopenia following dental treatment. The thrombocytopenia was acknowledged due to unexpected hemorrhaging during the procedures. On both occasions, he was exposed to four different drugs, none commonly associated with DITP. After the second episode of severe procedural‐related thrombocytopenia, an investigation into the cause was initiated. We describe the clinical approach to elucidate which of the four implicated drugs was responsible for thrombocytopenia and the laboratory work‐up done to confirm that the reaction was antibody‐mediated and identify the antibody's drug: glycoprotein specificity. An alternative drug was tested both in vivo and in vitro, to identify an option for future procedures. Results Sequential exposure revealed the local anesthetic substance articaine to induce thrombocytopenia. Laboratory work‐up confirmed drug‐dependent antibodies (DDAbs) with specificity for the glycoprotein Ib/IX complex, swiftly identified by a bead‐based Luminex assay. Further investigations by monoclonal antibody immobilization of platelet antigens assay (MAIPA) revealed a probable GPIb binding site. An alternative local anesthetic, lidocaine, was deemed safe for future procedures. Conclusion Articaine can induce rapid‐onset, severe immune‐mediated thrombocytopenia causing bleeding complications. A modified bead‐based Luminex platelet antigen assay proved a useful addition in the DITP‐investigation.
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Affiliation(s)
- Ingvild Jenssen Lægreid
- The Norwegian National Unit for Platelet Immunology, Department of Laboratory medicineUniversity Hospital of North NorwayTromsøNorway
| | - Mats Irgen Olsen
- Department of Hematology, Division of Internal MedicineUniversity Hospital of North NorwayTromsøNorway
| | - Jon Inge Harr
- Department of Anesthesiology Narvik, Division of Surgical Medicine and Intensive CareUniversity Hospital of North NorwayNarvikNorway
| | - Renathe Henriksen Grønli
- The Norwegian National Unit for Platelet Immunology, Department of Laboratory medicineUniversity Hospital of North NorwayTromsøNorway
| | - Trude Victoria Mørtberg
- The Norwegian National Unit for Platelet Immunology, Department of Laboratory medicineUniversity Hospital of North NorwayTromsøNorway
| | - Siw Leiknes Ernstsen
- The Norwegian National Unit for Platelet Immunology, Department of Laboratory medicineUniversity Hospital of North NorwayTromsøNorway
| | - Maria Therese Ahlen
- The Norwegian National Unit for Platelet Immunology, Department of Laboratory medicineUniversity Hospital of North NorwayTromsøNorway
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6
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Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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7
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Kuwabara G, Tazoe K, Imoto W, Yamairi K, Shibata W, Oshima K, Yamada K, Takagi Y, Shiraishi S, Hino M, Kawaguchi T, Kakeya H. Isoniazid-induced Immune Thrombocytopenia. Intern Med 2021; 60:3639-3643. [PMID: 34053983 PMCID: PMC8666230 DOI: 10.2169/internalmedicine.6520-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Drug-induced thrombocytopenia occurs through immune-mediated platelet destruction, and its management is challenging during tuberculosis treatment. Although rifampicin is the most common drug causing thrombocytopenia, isoniazid can also cause thrombocytopenia. We herein report a 75-year-old man who developed thrombocytopenia during tuberculosis treatment. Platelet-associated immunoglobulin G and a drug-induced lymphocyte stimulation test for isoniazid were positive; no other causes of thrombocytopenia were identified. The patient was diagnosed with isoniazid-induced immune thrombocytopenia, and the platelet count normalized after isoniazid discontinuation. We describe the immunological mechanism of thrombocytosis due to isoniazid, an uncommon cause of thrombocytopenia that physicians should be aware exists.
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Affiliation(s)
- Gaku Kuwabara
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Japan
| | - Kumiyo Tazoe
- Department of Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Waki Imoto
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Japan
| | - Kazushi Yamairi
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
| | - Wataru Shibata
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
| | - Kazuhiro Oshima
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
| | - Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
| | - Yasuhiro Takagi
- Department of Respiratory Medicine, Osaka City Juso Hospital, Japan
| | | | - Masayuki Hino
- Department of Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Tomoya Kawaguchi
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Japan
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8
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Koumpis E, Papathanasiou K, Papakonstantinou I, Tassi I, Serpanou A, Kapsali E, Hatzimichael E. Rifampicin-Induced Thrombocytopenia: A Case Report and Short Review of the Literature. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Thrombocytopenia may be associated with a variety of conditions and risks depending on its severity, ranging from mild epistaxis to life-threating bleeding. Many drugs or herbal remedies can cause thrombocytopenia by either inhibiting platelet production and/or enhancing their destruction from the peripheral blood mediated via an immunological mechanism implicating drug-dependent antibodies. The latter entity is called drug-induced immune thrombocytopenia: a life-threatening, under-recognised condition, which is often a diagnostic challenge. Rifampicin is a widely used, well-tolerated, and effective bactericidal drug. Adverse events, except for gastrointestinal effects, headache, skin rash, and pruritus, are uncommon. The authors herein report on a patient with isolated thrombocytopenia with a recent medical history of brucellosis on rifampicin and doxycycline. Thrombocytopenia was proved to be rifampicin-induced. Also presented is a short review of the literature on this rare subject, which should be of great importance to clinicians.
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Affiliation(s)
- Epameinondas Koumpis
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Konstantina Papathanasiou
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Ioannis Papakonstantinou
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Iliana Tassi
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Anastasia Serpanou
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Eleni Kapsali
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Eleftheria Hatzimichael
- Department of Haematology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
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9
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Ngo ATP, Parra-Izquierdo I, Aslan JE, McCarty OJT. Rho GTPase regulation of reactive oxygen species generation and signalling in platelet function and disease. Small GTPases 2021; 12:440-457. [PMID: 33459160 DOI: 10.1080/21541248.2021.1878001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Platelets are master regulators and effectors of haemostasis with increasingly recognized functions as mediators of inflammation and immune responses. The Rho family of GTPase members Rac1, Cdc42 and RhoA are known to be major components of the intracellular signalling network critical to platelet shape change and morphological dynamics, thus playing a major role in platelet spreading, secretion and thrombus formation. Initially linked to the regulation of actomyosin contraction and lamellipodia formation, recent reports have uncovered non-canonical functions of platelet RhoGTPases in the regulation of reactive oxygen species (ROS), where intrinsically generated ROS modulate platelet function and contribute to thrombus formation. Platelet RhoGTPases orchestrate oxidative processes and cytoskeletal rearrangement in an interconnected manner to regulate intracellular signalling networks underlying platelet activity and thrombus formation. Herein we review our current knowledge of the regulation of platelet ROS generation by RhoGTPases and their relationship with platelet cytoskeletal reorganization, activation and function.
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Affiliation(s)
- Anh T P Ngo
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Ivan Parra-Izquierdo
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph E Aslan
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA.,Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, Oregon, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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10
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Affiliation(s)
- Harpreet Singh
- Department of Emergency Medicine, GMCH, Chandigarh, India
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11
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Muhammad S, Naeem A, Shaukat A, Javaid S, Alvi S. Drug-Induced Immune Thrombocytopenia From Administration of a Local Anesthetic Agent Resulting in Splenectomy. Cureus 2020; 12:e8293. [PMID: 32601567 PMCID: PMC7317117 DOI: 10.7759/cureus.8293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Thrombocytopenia is a common clinical condition, and drug-induced immune thrombocytopenia (DITP) should be considered in hospitalized patients with severe thrombocytopenia who are exposed to new medications. The potential mechanism is described to be drug-triggered antibody-mediated platelet destruction causing petechiae and mucosal bleeding. Severe form of DITP can be refractory to systemic steroids and even intravenous immunoglobulin administration. Such cases usually require splenectomy for definitive treatment. A number of substances including medications, herbal remedies, and even food items have been identified with a definitive or probable causal role in DITP. However, it is rarely reported from locally administered medications such as local anesthetic drugs. We present a unique case of severe DITP from lidocaine that resulted in refractory DITP requiring splenectomy for definitive treatment.
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Affiliation(s)
- Safwan Muhammad
- Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Ammad Naeem
- Internal Medicine, University at Buffalo, Buffalo, USA
| | - Amna Shaukat
- Internal Medicine, Services Institute of Medical Sciences, Lahore, PAK
| | - Subas Javaid
- Internal Medicine, Liaquat National Medical College, Karachi, PAK
| | - Saqib Alvi
- Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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12
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Al Ghamdi RM, Turkistani AN, Ben Ali H. Phenytoin Seizure Prophylaxis Therapy Resulting in Severe Thrombocytopenia After Brain Tumor Debulking Surgery. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e919828. [PMID: 31996666 PMCID: PMC7006599 DOI: 10.12659/ajcr.919828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient: Male, 40-year-old Final Diagnosis: Phenytoin-induced thrombocytopenia Symptoms: Thrombocytopenia Medication: Phenytoin Clinical Procedure: Tumor debulking surgery Specialty: Neurosurgery
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Affiliation(s)
- Rawan M Al Ghamdi
- Department of Pharmacy, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Alaa N Turkistani
- Department of Neurosurgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Haitham Ben Ali
- Department of Neurosurgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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13
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Piedra Abusharar S, Shah N, Patel R, Jain R, Polimera HV. A Case of Confirmed Ceftriaxone-induced Immune Thrombocytopenia. Cureus 2019; 11:e4688. [PMID: 31338265 PMCID: PMC6639063 DOI: 10.7759/cureus.4688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Drug-induced immune thrombocytopenia (DITP) is a rare, but potentially fatal cause of isolated thrombocytopenia. DITP is thought to occur when drug-dependent antibodies bind to the platelet membrane glycoproteins to activate platelet consumption signaling. Common implicated drugs include quinine/quinidine, penicillamines, valproic acid and cotrimoxazole. Ceftriaxone is a rare culprit with only six reported cases since 1991, of which only three were confirmed with drug-dependent antiplatelet antibodies. We describe a case of antibody confirmed ceftriaxone-induced immune thrombocytopenia after initiation of empiric antibiotic therapy for acute bacterial meningitis.
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Affiliation(s)
- Shady Piedra Abusharar
- Internal Medicine, Penn State College of Medicine/ Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Neal Shah
- Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Ravi Patel
- Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Rohit Jain
- Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Hyma V Polimera
- Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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14
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Recinella G, De Marchi A, Pirazzoli E, Bianchi G. Probable Etoricoxib-Induced Severe Thrombocytopenia: A Case Report. Med Princ Pract 2019; 28:387-389. [PMID: 30650407 PMCID: PMC6639571 DOI: 10.1159/000496975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/16/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe a case of likely etoricoxib-induced severe thrombocytopenia. CLINICAL PRESENTATION AND INTERVENTION A 32-year-old woman was referred to our hospital for disseminated petechial rash after 7 days of therapy with etoricoxib. At admission, the patient's platelet count was 3,000/mm3. At Naranjo's scale correlation between thrombocytopenia and drug was considered as "probable." With the diagnostic tests performed we did not find other causes of thrombocytopenia. Etoricoxib was discontinued. The patient was treated with intravenous immunoglobulin and corticosteroids with a complete resolution of the thrombocytopenia in a few days. CONCLUSION The prevalence of thrombocytopenia induced by etoricoxib should be studied as it may not be very rare.
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Affiliation(s)
- Guerino Recinella
- Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy,
| | - Alessandro De Marchi
- Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Enrico Pirazzoli
- Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giampaolo Bianchi
- Division of Internal Medicine, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
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15
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Nagrebetsky A, Al-Samkari H, Davis N, Kuter D, Wiener-Kronish J. Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. Br J Anaesth 2019; 122:19-31. [DOI: 10.1016/j.bja.2018.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 01/19/2023] Open
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16
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17
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Gerstein W, Colombo E, Harji F. Documented vancomycin-induced severe immune-mediated thrombocytopaenia. BMJ Case Rep 2018; 2018:bcr-2018-224682. [PMID: 30150336 DOI: 10.1136/bcr-2018-224682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
A 69-year-old man developed Propionibacterium acnes left knee hardware infection after suffering from an infected ingrown toenail. The hardware was removed and he was treated with intravenous vancomycin. Ten days after initiation of vancomycin, he developed severe thrombocytopaenia, epistaxis and petechiae. Vancomycin was discontinued, and platelets rapidly recovered. Serum vancomycin IgG were positive. Patient completed a 6-week course of ceftriaxone with no further complications.
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Affiliation(s)
- Wendy Gerstein
- Department of Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA.,Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Elizabeth Colombo
- Department of Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA.,Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Farzana Harji
- Department of Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA.,Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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18
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A Case of Hyperacute Severe Thrombocytopenia Occurring Less than 24 Hours after Intravenous Tirofiban Infusion. Case Rep Hematol 2018; 2018:4357981. [PMID: 29977628 PMCID: PMC5994276 DOI: 10.1155/2018/4357981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/24/2018] [Accepted: 05/10/2018] [Indexed: 01/02/2023] Open
Abstract
Thrombocytopenia is defined as a condition where the platelet count is below the lower limit of normal (<150 G/L), and it is categorized as mild (100–149 G/L), moderate (50–99 G/L), and severe (<50 G/L). We present here a 79-year-old man who developed severe thrombocytopenia with a platelet count of 6 G/L, less than 24 hours after intravenous tirofiban infusion that was given to the patient during a percutaneous transluminal coronary angioplasty procedure with placement of 3 drug-eluting stents. The patient's baseline platelet count was 233 G/L before the procedure. Based on the timeline of events during hospitalization and laboratory evidence, it was highly likely that the patient's thrombocytopenia was the result of tirofiban-induced immune thrombocytopenia, a type of drug-induced immune thrombocytopenia (DITP) which occurs due to drug-dependent antibody-mediated platelet destruction. Anticoagulant-mediated artefactual pseudothrombocytopenia was ruled out as no platelet clumping was seen on the peripheral blood smears. The treatment of DITP includes discontinuation of the causative drug; monitoring of platelet count recovery; or treatment of severe thrombocytopenia with glucocorticoids, IVIG, or platelet transfusions depending on the clinical presentation. The most likely causative agent of this patient's thrombocytopenia—tirofiban—was discontinued, and the patient did not develop any signs of bleeding during the remainder of his hospital stay. His platelet count gradually improved to 24 G/L, and he was discharged on the sixth hospital day.
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Abstract
Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.
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Nixon CP, Cheves TA, Sweeney JD. Sulfamethoxazole-induced thrombocytopenia masquerading as posttransfusion purpura: a case report. Transfusion 2015; 55:2738-41. [PMID: 26098194 DOI: 10.1111/trf.13197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 05/01/2015] [Accepted: 05/10/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Drug-induced immune thrombocytopenia (DITP) is a rare clinical disorder characterized by accelerated platelet (PLT) clearance in the presence of drug-dependent antibodies. Distinguishing DITP from other immune-mediated disorders such as posttransfusion purpura (PTP) and autoimmune thrombocytopenia can represent a clinical challenge. CASE REPORT A 68-year-old male with no prior transfusion history presented to the emergency department (ED) with dyspnea, epistaxis, and severe thrombocytopenia (<10 × 10(9)/L) 12 days after discharge from a hospital admission for a coronary artery bypass graft. Evaluation of the degree of thrombocytopenia and the temporal association between the peri- and postoperative receipt of multiple transfusions and the acute decrease in PLT count indicated PTP as a possible cause of the severe thrombocytopenia. Treatment with 1 g/kg intravenous immunoglobulin (IVIG) was initiated and followed by a rapid 48-hour increase in the PLT count. PLT antibodies lacking serologic specificity were subsequently identified in a sample collected upon presentation. Two weeks later he again presented to the ED with epistaxis and severe thrombocytopenia (<10 × 10(9)/L). Clinical history now revealed that the patient had been treated with trimethoprim-sulfamethoxazole by his primary care physician after his first hospitalization for a "cellulitic-appearing" leg and again before his final presentation for surgical site erythema and edema. IVIG was administered again with a rapid return of PLT count to baseline. Sulfamethoxazole-dependent PLT antibodies were subsequently identified in the original patient sample. CONCLUSION This case report documents a case of IVIG-responsive DITP initially misdiagnosed as PTP, highlighting the clinical overlap of these immunologic-mediated phenomena.
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Affiliation(s)
- Christian P Nixon
- Center for International Health Research, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tracey A Cheves
- Department of Pathology & Laboratory Medicine, Rhode Island Hospital and the Miriam Hospitals, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joseph D Sweeney
- Department of Pathology & Laboratory Medicine, Rhode Island Hospital and the Miriam Hospitals, Alpert Medical School of Brown University, Providence, Rhode Island
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Mansour H, Saad A, Azar M, Khoueiry P. Amoxicillin/Clavulanic Acid-induced thrombocytopenia. Hosp Pharm 2014; 49:956-60. [PMID: 25477568 PMCID: PMC4252219 DOI: 10.1310/hpj4910-956] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND OBJECTIVE Drug-induced thrombocytopenia is a common adverse effect reported in the literature. Typically patients present with a low platelet count with signs and symptoms ranging from bruising to bleeding, and major organ damage. Penicillin-induced thrombocytopenia previously reported in the literature is explained primarily through the hapten-dependent antibody process. The goal of this report is to present a case of an amoxicillin/clavulanic acid-induced thrombocytopenia. CASE PRESENTATION A 23-year-old male presented to the emergency department with bruises on his arms and legs after completing a full course of amoxicillin/clavulanic acid of 625 mg twice a day for 5 days for tonsillitis. After several tests, the patient was diagnosed with thrombocytopenia induced by amoxicillin/clavulanic acid. The patient was treated with a corticosteroids taper regimen for 3 weeks. He was discharged after 3 days of inpatient treatment with instructions to avoid physical activity for 2 weeks. Two weeks post discharge, the follow-up showed that the platelet count had increased. DISCUSSION Penicillin-induced thrombocytopenia has been previously reported in the inpatient setting where bleeding was observed. However, the patient in this case report presented with bruises on his arms and legs. The diagnosis was made by the process of elimination; not all possible tests were conducted. The patient was prescribed corticosteroids that are not indicated for drug-induced thrombocytopenia. The Naranjo scale showed that this is a probable adverse event of amoxicillin/clavulanic acid. CONCLUSION This is a unique case where amoxicillin/clavulanic acid was reported to be a probable cause of thrombocytopenia in an outpatient setting without signs of bleeding and without concomitant medications.
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Affiliation(s)
- Hanine Mansour
- Clinical Assistant Professor, Lebanese American University School of Pharmacy, Byblos, Lebanon
| | - Aline Saad
- Clinical Assistant Professor, Lebanese American University School of Pharmacy, Byblos, Lebanon
- Chairperson of Pharmacy Practice Department, Lebanese American University School of Pharmacy, Byblos, Lebanon
| | - Marina Azar
- Lebanese American University School of Pharmacy, Byblos, Lebanon
| | - Paul Khoueiry
- Hematology/Oncology Specialist, Centre Hospitalier Universitaire, Notre Dame De Secours, Jbeil, Lebanon
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Giupponi L, Cantoni S, Morici N, Sacco A, Giannattasio C, Klugmann S, Savonitto S. Delayed, severe thrombocytemia after abciximab infusion for primary angioplasty in acute coronary syndromes: Moving between systemic bleeding and stent thrombosis. Platelets 2014; 26:498-500. [DOI: 10.3109/09537104.2014.898181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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23
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Curtis BR. Drug-induced immune thrombocytopenia: incidence, clinical features, laboratory testing, and pathogenic mechanisms. Immunohematology 2014; 30:55-65. [PMID: 25247620 DOI: 10.21307/immunohematology-2019-099] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Drug-induced immune thrombocytopenia (DIIT) is a relatively uncommon adverse reaction caused by drug-dependent antibodies (DDAbs) that react with platelet membrane glycoproteins only when the implicated drug is present. Although more than 100 drugs have been associated with causing DIIT, recent reviews of available data show that carbamazepine, eptifibatide, ibuprofen, quinidine, quinine, oxaliplatin, rifampin, sulfamethoxazole, trimethoprim, and vancomycin are probably the most frequently implicated. Patients with DIIT typically present with petechiae, bruising, and epistaxis caused by an acute, severe drop in platelet count (often to <20,000 platelets/pL). Diagnosis of DIIT is complicated by its similarity to other non-drug-induced immune thrombocytopenias, including autoimmune thrombocytopenia, posttransfusion purpura, and platelet transfusion refractoriness, and must be differentiated by temporal association of exposure to a candidate drug with an acute, severe drop in platelet count. Treatment consists of immediate withdrawal of the implicated drug. Criteria for strong evidence of DIIT include (1) exposure to candidate drug-preceded thrombocytopenia; (2) sustained normal platelet levels after discontinuing candidate drug; (3) candidate drug was only drug used before onset of thrombocytopenia or other drugs were continued or reintroduced after resolution of thrombocytopenia, and other causes for thrombocytopenia were excluded; and (4) reexposure to the candidate drug resulted in recurrent thrombocytopenia. Flow cytometry testing for DDAbs can be useful in confirmation of a clinical diagnosis, and monoclonal antibody enzyme-linked immunosorbent assay testing can be used to determine the platelet glycoprotein target(s), usually GPIIb/IIIa or GPIb/IX/V, but testing is not widely available. Several pathogenic mechanisms for DIIT have been proposed, including hapten, autoantibody, neoepitope, drug-specific, and quinine-type drug mechanisms. A recent proposal suggests weakly reactive platelet autoantibodies that develop greatly increased affinity for platelet glycoprotein epitopes through bridging interactions facilitated by the drug is a possible mechanism for the formation and reactivity of quinine- type drug antibodies.
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Affiliation(s)
- Brian R Curtis
- PhD, D(ABMLI), MT(ASCP)SBB, Director, Platelet and Neutrophil Immunology Lab, Blood Research Institute, BloodCenter of Wisconsin, PO Box 2178, Milwaukee, WI 53201-2178
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Chong BH, Choi PYI, Khachigian L, Perdomo J. Drug-induced immune thrombocytopenia. Hematol Oncol Clin North Am 2013; 27:521-40. [PMID: 23714310 DOI: 10.1016/j.hoc.2013.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Thrombocytopenia is caused by immune reactions elicited by diverse drugs in clinical practice. The activity of the drug-dependent antibodies produces a marked decrease in blood platelets and a risk of serious bleeding. Understanding of the cellular mechanisms that drive drug-induced thrombocytopenia has advanced recently but there is still a need for improved laboratory tests and treatment options. This article provides an overview of the different types of drug-induced thrombocytopenia, discusses potential pathologic mechanisms, and considers diagnostic methods and treatment options.
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Affiliation(s)
- Beng H Chong
- Haematology Department, St George Hospital, Kogarah, NSW 2217, Australia.
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25
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Teke HÜ, Teke D. Profound thrombocytopenia related with tirofiban: will it be enough to only stop medicine? Platelets 2012; 24:335-7. [PMID: 22720791 DOI: 10.3109/09537104.2012.696749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Agrawal A, Gutch M, Jain N, Singh A. Do not miss rifampicin-induced thrombocytopenic purpura. BMJ Case Rep 2012; 2012:bcr.12.2011.5282. [PMID: 22665562 DOI: 10.1136/bcr.12.2011.5282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Drug-induced immune thrombocytopenia (DITP) can be triggered by a wide range of medications. Although many cases of DITP are mild, some are characterised by life-threatening bleeding symptoms. In the treatment of tuberculosis there are special therapeutic problems related to adverse effects of drugs, compliance to treatment and microbial resistance. Thrombocytopenia is an uncommon but potentially fatal adverse effect of certain antituberculous drugs when the incriminating drug is taken by a susceptible individual. Here the authors report a case of rifampicin-induced thrombocytopenia, which although rare, needs attention.
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Affiliation(s)
- Avinash Agrawal
- Department of Internal Medicine, CSM Medical University, Lucknow, Uttar Pradesh, India.
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Lee EJ, Lee SH, Kim YE, Lee SJ, Cho YJ, Jeong YY, Kim HC, Lee JD, Hwang YS. A case of isoniazid-induced thrombocytopenia: recovery with immunoglobulin therapy. Intern Med 2012; 51:745-8. [PMID: 22466831 DOI: 10.2169/internalmedicine.51.6296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Treatment for a 51-year-old man with pulmonary tuberculosis was initiated with isoniazid, rifampicin, ethambutol, and pyrazinamide, and discontinued after 3 weeks because of skin rash and itchiness. Isoniazid monotherapy was restarted after 2 weeks. Two days later, the platelet count decreased from 150 to 4×10(3)/mm(3). Despite platelet transfusion and oral corticosteroid treatment, the platelet count did not recover. However, after a 2-day administration of intravenous immunoglobulin, the platelet count recovered to 209×10(3)/mm(3). This report describes a case of isoniazid-induced thrombocytopenia that was reversed with intravenous immunoglobulin, thus highlighting the efficacy of this treatment for this rare condition.
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Affiliation(s)
- Eun Ju Lee
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Korea
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28
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Patel N, VanDeWall H, Tristani L, Rivera A, Woo B, Dihmess A, Li HK, Smith R, Lodise TP. A comparative evaluation of adverse platelet outcomes among Veterans' Affairs patients receiving linezolid or vancomycin. J Antimicrob Chemother 2011; 67:727-35. [PMID: 22174041 DOI: 10.1093/jac/dkr522] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The primary objectives were to compare the incidences of severe thrombocytopenia, critical thrombocytopenia and a relative decline in platelets from baseline (≥50% decline) between patients receiving linezolid and those receiving vancomycin. The secondary objective was to assess the relationship between vancomycin trough concentration and adverse platelet outcomes. METHODS A matched cohort study was performed at the Upstate New York Veterans' Affairs Healthcare Network from January 2005 until February 2008. Eligibility criteria were: (i) receipt of linezolid or vancomycin therapy for ≥48 h; (ii) initiation of therapy as an inpatient; and (iii) baseline platelets available for evaluation. Patients who received linezolid were matched 1:1 to patients who received vancomycin. Cumulative incidences and times to event for (i) platelet count ≤50,000 cells/mm(3), (ii) platelet count ≤20,000 cells/mm(3) and (iii) ≥50% decline in platelets from baseline were evaluated. Multivariate analyses were performed. RESULTS The study included 502 patients (251 matched pairs). The occurrences of platelet counts ≤50,000 cells/mm(3) and ≤20,000 cells/mm(3) did not differ significantly between linezolid and vancomycin patients. A ≥50% decline in platelets from baseline was observed in 78 (31.1%) patients receiving vancomycin and 43 (17.1%) patients receiving linezolid (risk ratio 0.55; 95% CI 0.40-0.77). A clear exposure-response relationship was observed between vancomycin trough concentration and ≥50% decline in platelets from baseline. CONCLUSIONS The incidence of thrombocytopenia was low and did not differ significantly among vancomycin and linezolid patients.
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Affiliation(s)
- Nimish Patel
- Albany College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Albany, NY 12208, USA
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29
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A distinctive form of immune thrombocytopenia in a phase 2 study of alemtuzumab for the treatment of relapsing-remitting multiple sclerosis. Blood 2011; 118:6299-305. [PMID: 21960587 DOI: 10.1182/blood-2011-08-371138] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In a phase 2 clinical trial of annual alemtuzumab for treatment of relapsing-remitting multiple sclerosis, 6 of 216 patients (2.8%) developed immune thrombocytopenia (ITP). Over mean follow-up of 4.5 years, the incidence rate of ITP was 6.2 (95% confidence interval, 2.3-13.3) per 1000 person-years. Median times from initial and last alemtuzumab exposure to ITP diagnosis were 24.5 and 10.5 months, respectively. Five patients developed severe thrombocytopenia. Four were symptomatic, including fatal intracranial hemorrhage in the index case. Four patients received standard first-line ITP therapy, all of whom responded to treatment within 1 week. All 5 surviving patients achieved complete remission and remained in complete remission without need for ongoing ITP therapy for a median duration of 34 months at last follow-up. A monitoring plan for the early detection of ITP, implemented after presentation of the index case, identified all 5 subsequent cases before serious hemorrhagic morbidity or mortality occurred. In conclusion, we describe a distinctive form of ITP associated with alemtuzumab treatment characterized by delayed presentation after drug exposure, responsiveness to conventional ITP therapies, and prolonged remission. Clinicians should maintain a high level of vigilance and consider routine monitoring for ITP in patients treated with this agent. This trial was registered at www.clinicaltrials.gov as #NCT00050778.
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30
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Rashidi A, Rizvi N. Octreotide-induced thrombocytopenia: a case report. J Med Case Rep 2011; 5:286. [PMID: 21729263 PMCID: PMC3141722 DOI: 10.1186/1752-1947-5-286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 07/05/2011] [Indexed: 11/30/2022] Open
Abstract
Introduction Thrombocytopenia is an extremely rare complication of octreotide therapy and can be life threatening in the setting of esophageal variceal bleeding. We report a case of octreotide-induced reversible thrombocytopenia in a 54-year-old Caucasian man with alcohol-induced cirrhosis and upper gastrointestinal bleeding. Case presentation Our patient's platelet count dropped from 155,000/mm3 upon admission to 77,000/mm3 a few hours after initiation of octreotide therapy and stayed low until the drug's administration was discontinued. Significant recovery was achieved quickly after discontinuation of octreotide. Conclusions Thrombocytopenia is a rare but potentially serious side effect of octreotide therapy and may complicate esophageal variceal bleeding. Physicians should be vigilant in identifying this potentially serious condition.
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Affiliation(s)
- Armin Rashidi
- Department of Internal Medicine, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 410, Norfolk, VA 23507, USA.
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31
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Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 651] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
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Lai JN, Hsieh SC, Chen PC, Chen HJ, Wang JD. Should herbs take all the blame? Causality assessment of a serious thrombocytopenia event. J Altern Complement Med 2010; 16:1221-4. [PMID: 20979526 DOI: 10.1089/acm.2010.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With the increasing use of herbal medicines, the causality assessment of adverse drug-related reactions becomes more complicated because of the concomitant use of herbs and conventional medications. Epidemiological causal inference can be a central feature of such judgment but may be insufficient. Other scientific considerations include study design, bias, confounding, and measurement issues. The approach of this study is to establish an active safety surveillance system for finished herbal products (FHPs) and to review each adverse event regularly. METHOD A single case of serious thrombocytopenia was found in 136 subjects taking FHPs on a clinical trial for 12 weeks, for which the cause was sought. RESULTS Because at the end of the first month the patient's platelet counts were normal and the thrombocytopenia developed after the co-medication with conventional drugs, it was suspected that the thrombocytopenia might not be attributed to the use of FHP. CONCLUSIONS This report summarizes the criteria of causality assessment under mixed use of herbs and conventional medicine and recommends a feasible process for careful evaluation of adverse drug reactions related to all herbal medicine.
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Affiliation(s)
- Jung-Nien Lai
- Department of Obstetrics and Gynecology, Taipei City Hospital, Yangming Branch, Taipei, Taiwan
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Verma AK, Singh A, Chandra A, Kumar S, Gupta RK. Rifampicin-induced thrombocytopenia. Indian J Pharmacol 2010; 42:240-2. [PMID: 20927251 PMCID: PMC2941616 DOI: 10.4103/0253-7613.68432] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 04/17/2010] [Accepted: 06/24/2010] [Indexed: 11/24/2022] Open
Abstract
In the treatment of tuberculosis there are special therapeutic problems related to adverse effects of drugs, compliance to treatment, and microbial resistance. Thrombocytopenia is an uncommon but potentially fatal adverse effect of certain anti-tubercular drugs when the incriminating drug is taken by a susceptible individual. We report a case of rifampicin-induced thrombocytopenia, which although rare, needs attention.
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Affiliation(s)
- Ajay Kumar Verma
- Department of TB and Chest Diseases, S.N. Medical College, Agra - 282 002, India
| | - Arpita Singh
- Department of Pharmacology, GSVM Medical College, Kanpur - 208 002, India
| | - Amol Chandra
- Department of TB and Chest Diseases, S.N. Medical College, Agra - 282 002, India
| | - Santosh Kumar
- Department of TB and Chest Diseases, S.N. Medical College, Agra - 282 002, India
| | - Rajesh Kumar Gupta
- Department of TB and Chest Diseases, S.N. Medical College, Agra - 282 002, India
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Narayanan D, Kilpatrick ES. Atorvastatin-related thrombocytopenic purpura. BMJ Case Rep 2010; 2010:2010/may19_1/bcr0120102614. [PMID: 22750917 DOI: 10.1136/bcr.01.2010.2614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 44-year-old male patient with a single vessel ischaemic heart disease was referred to the lipid clinic for management of hypercholesterolaemia after an episode of admission with thrombocytopenic purpura secondary to atorvastatin. Atorvastatin was discontinued and his platelet counts improved gradually with steroids. He is now established on a different statin with no further episodes of thrombocytopenia. Though a drug challenge was never done, an idiosyncratic reaction to the initial statin seems to be the most likely cause.
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Affiliation(s)
- Deepa Narayanan
- Clinical Biochemistry, Pathology Department, Hull Royal Infirmary, Hull, UK.
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Serraj K, Mecili M, Aouni M, Maaouni A, Andrès E. Les thrombopénies médicamenteuses idiosyncrasiques. Rev Med Interne 2009; 30:866-71. [DOI: 10.1016/j.revmed.2009.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 02/24/2009] [Accepted: 02/25/2009] [Indexed: 10/20/2022]
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Andres E, Dali-Youcef N, Serraj K, Zimmer J. Recognition and management of drug-induced cytopenias: the example of idiosyncratic drug-induced thrombocytopenia. Expert Opin Drug Saf 2009; 8:183-90. [DOI: 10.1517/14740330902784162] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Drug-induced thrombocytopenia (DIT) is a relatively common clinical disorder. It is imperative to provide rapid identification and removal of the offending agent before clinically significant bleeding or, in the case of heparin, thrombosis occurs. DIT can be distinguished from idiopathic thrombocytopenic purpura, a bleeding disorder caused by thrombocytopenia not associated with a systemic disease, based on the history of drug ingestion or injection and laboratory findings. DIT disorders can be a consequence of decreased platelet production (bone marrow suppression) or accelerated platelet destruction (especially immune-mediated destruction).
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Affiliation(s)
- Gian Paolo Visentin
- Department of Pediatrics, University at Buffalo, The State University of New York, 3435 Main Street BRB, Room 422, Buffalo, NY 14214, USA.
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38
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Warkentin TE. Clinical Picture of Heparin-Induced Thrombocytopenia. HEPARIN-INDUCED THROMBOCYTOPENIA 2007. [DOI: 10.3109/9781420045093.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Thrombocytopenia can have several causes, including the use of certain drugs. The mechanism behind drug-induced thrombocytopenia is either a decrease in platelet production (bone marrow toxicity) or an increased destruction (immune-mediated thrombocytopenia). In addition, pseudothrombocytopenia, an in vitro effect, has to be distinguished from true drug-induced thrombocytopenia. This article reviews literature on drug-induced immune thrombocytopenia, with the exception of thrombo-haemorrhagic disorders such as thrombotic thrombocytopenic purpura and heparin-induced thrombocytopenia and thrombosis. A literature search in PubMed combined with a check of the reference lists of all the retrieved articles resulted in 108 articles relevant to the subject. The drug classes that are most often associated with drug-induced immune thrombocytopenia are cinchona alkaloid derivatives (quinine, quinidine), sulfonamides, NSAIDs, anticonvulsants, disease modifying antirheumatic drugs and diuretics. Several other drugs are occasionally described in case reports of thrombocytopenia; an updated review of these case reports can be found on the internet. A small number of epidemiological studies, differing largely in the methodology used, describe incidences in the magnitude of 10 cases per 1 000 000 inhabitants per year. No clear risk factors could be identified from these studies. The underlying mechanism of drug-induced immune thrombocytopenia is not completely clarified, but at least three different types of antibodies appear to play a role (hapten-dependent antibodies, drug-induced, platelet-reactive auto-antibodies and drug-dependent antibodies). Targets for drug-dependent antibodies are glycoproteins on the cell membrane of the platelets, such as glycoprotein (GP) Ib/IX and GPIIb/IIIa. Diagnosis of drug-induced immune thrombocytopenia may consist of identifying clinical symptoms (bruising, petechiae, bleeding), a careful evaluation of the causal relationship of the suspected causative drug, general laboratory investigation, such as total blood count and peripheral blood smear (to rule out pseudothrombocytopenia), and platelet serology tests. The sensitivity of these tests is dependent on factors such as the concentration of the drug in the test and the potential sensitisation of the patient by metabolites instead of the parent drug. Drug-induced immune thrombocytopenia can be treated by withholding the causative drug and, in severe cases associated with bleeding, by platelet transfusion. Although drug-induced thrombocytopenia is a relatively rare adverse drug reaction, its consequences may be severe. Therefore it is important to extend our knowledge on this subject. Future research should focus on the identification of potential risk factors, as well as the exact mechanism underlying drug-induced thrombocytopenia.
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Dorsch MP, Montague D, Rodgers JE, Patterson C. Abciximab-Associated Thrombocytopenia After Previous Tirofiban-Related Thrombocytopenia. Pharmacotherapy 2006; 26:423-7. [PMID: 16503724 DOI: 10.1592/phco.26.3.423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 62-year-old man with a history of coronary artery disease and coronary artery bypass graft, chronic heart failure, and peripheral vascular disease required percutaneous coronary intervention (PCI) after progression of shortness of breath and fatigue over 2 years. Four hours after the procedure, the patient developed hematemesis and was found to be thrombocytopenic. The thrombocytopenia was presumed to be due to the abciximab infusion the patient received during and shortly after the PCI. Further review of the patient's medical history revealed that a similar episode had occurred 11 years earlier. At that time, he was enrolled in a clinical trial comparing tirofiban and heparin in patients with unstable angina; he developed profound thrombocytopenia within 24 hours of randomization. After the study unblinding, investigators discovered that the patient received tirofiban, which was thought to be the cause of his thrombocytopenia. Both abciximab and tirofiban are glycoprotein IIb-IIIa inhibitors, and thrombocytopenia induced by this class of drugs is a serious and potentially life-threatening adverse reaction. The mechanism is not well understood but has been described as immune mediated with both ligand-mimetic agents (tirofiban and eptifibatide) and abciximab. Our patient's situation was unusual in that he developed thrombocytopenia from a ligand-mimetic agent and subsequently had a similar reaction to abciximab. To our knowledge, this case report is the first documentation of thrombocytopenia associated with both tirofiban and abciximab in a single patient, and suggests that care should be given in administering glycoprotein IIb-IIIa inhibitors of either type to patients with a history of thrombocytopenia due to one of these agents.
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Affiliation(s)
- Michael P Dorsch
- Department of Pharmacy Services, University of Michigan Hospitals and Health Clinics, Ann Arbor, Michigan 48109, USA.
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Huxtable LM, Tafreshi MJ, Rakkar ANS. Frequency and management of thrombocytopenia with the glycoprotein IIb/IIIa receptor antagonists. Am J Cardiol 2006; 97:426-9. [PMID: 16442410 DOI: 10.1016/j.amjcard.2005.08.066] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Revised: 08/22/2005] [Accepted: 08/22/2005] [Indexed: 10/25/2022]
Abstract
Glycoprotein IIb/IIIa receptor antagonists (GPRAs) are widely used in the management of a variety of patients with acute coronary syndromes. Major adverse reactions to these agents include bleeding and thrombocytopenia. Immune mechanisms responsible for severe thrombocytopenia seen with GPRAs have been hypothesized for all 3 agents currently available in the United States, although specific laboratory tests are not available for use in routine practice. A review of published research for GPRA-induced thrombocytopenia (GIT) is provided. Although the incidence of severe GIT is relatively low, the implications for patients are potentially life threatening. Prompt recognition of severe thrombocytopenia is essential to facilitate the necessary care of patients. Treatment strategies include the modification of drug regimens and other interventions targeting the reduction of immediate bleeding risk and the provision of supportive care measures. A review of published research supporting the conservative use of corticosteroids and intravenous gamma globulin in this syndrome is provided. Clinicians identifying severe thrombocytopenia after GPRA exposure are encouraged to report these events, following national and institutional guidelines.
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Affiliation(s)
- Lindsay M Huxtable
- Midwestern University College of Pharmacy-Glendale, Glendale, Arizona, USA.
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43
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Kim CK, Jang IS, Lee JH, Kwon YE, Park SC. Naproxen-induced Immune Thrombocytopenia -A case report-. Korean J Pain 2006. [DOI: 10.3344/kjp.2006.19.2.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Cheol Kun Kim
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - In Su Jang
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jun Hak Lee
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Young Eun Kwon
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sang Chul Park
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
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44
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&NA;. Drug-induced immune thrombocytopenia that increases platelet destruction results from antibody-related mechanisms. DRUGS & THERAPY PERSPECTIVES 2005. [DOI: 10.2165/00042310-200521120-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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45
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Abstract
Coagulation problems are very common in intensive care patients. It is important to recognize potential problems, perform a rapid assessment, and start therapy. The author reviews general clinical and laboratory approaches to diagnosis and treatment of the bleeding patient and to correction of coagulopathies. This review outlines a set of often catastrophic coagulation problems, which may present both thrombotic and bleeding challenges. These include heparin induced thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation.
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Affiliation(s)
- Thomas G DeLoughery
- Oregon Health & Science University, Hematology L586, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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46
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Abstract
A variety of disease states, disorders, hereditary conditions, environmental toxins, and drugs may cause thrombocytopenia. Fluoroquinolones, however, are not thought to be common offenders. We report the case of a 72-year-old woman who was receiving intravenous ciprofloxacin for a urinary tract infection and developed thrombocytopenia during her hospital stay. Her platelet count dropped from 147 x 10(3)/mm3 on admission to as low as 21 x 10(3)/mm3 . On discontinuation of the drug, her platelet counts began to return to normal. After discharge, the patient continued to improve clinically. Four days after discharge, her platelet count was 197 x 10(3)/mm3 . In the primary literature, we found two case reports on thrombocytopenia associated with ciprofloxacin and one case report with alatrofloxacin. In addition, six additional case reports were found in non-English journals that describe fluoroquinolone-associated thrombocytopenia. Clinicians should be aware of the possible relationship between thrombocytopenia and fluoroquinolones, and platelet counts should monitored accordingly.
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Affiliation(s)
- Jessica A Starr
- College of Pharmacy, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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47
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Winteroll S, Kerowgan M, Vahl CF, Leo A. Vancomycin-Mediated Drug-Induced Immune Thrombocytopenia. Transfus Med Hemother 2004. [DOI: 10.1159/000082126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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48
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Lagarce L, Boyer F, Bruhat C, Diquet B, Lainé-Cessac P. Thrombopénie sous aspirine, un effet indésirable souvent méconnu. Therapie 2004; 59:649-51. [PMID: 15789830 DOI: 10.2515/therapie:2004112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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49
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Arnold DM, Smaill F, Warkentin TE, Christjanson L, Walker I. Cardiobacterium hominis endocarditis associated with very severe thrombocytopenia and platelet autoantibodies. Am J Hematol 2004; 76:373-7. [PMID: 15282672 DOI: 10.1002/ajh.20127] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Severe thrombocytopenia is a life-threatening condition. It is often associated with immune-mediated platelet destruction or myeloablative chemotherapy. Infective endocarditis has been associated with thrombocytopenia, which, as in sepsis, tends to be mild and is often the result of several pathological mechanisms. We report a case of Cardiobacterium hominis endocarditis associated with very severe thrombocytopenia and bleeding in a patient who refused platelet transfusion. Platelet autoantibodies directed against glycoprotein (Gp) IIb/IIIa and Gp Ib/IX were detected during active infection using a glycoprotein-specific assay. Successful treatment of C. hominis endocarditis was associated with loss of platelet autoantibodies and recovery of the platelet count. This report illustrates that the development of platelet autoantibodies can contribute to very severe thrombocytopenia in occasional patients with infective endocarditis.
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Affiliation(s)
- Donald M Arnold
- Department of Hematology, McMaster University, Hamilton, Ontario, Canada
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50
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McGurrin MKJ, Arroyo LG, Bienzle D. Flow cytometric detection of platelet-bound antibody in three horses with immune-mediated thrombocytopenia. J Am Vet Med Assoc 2004; 224:83-7, 53. [PMID: 14710882 DOI: 10.2460/javma.2004.224.83] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Immune-mediated thrombocytopenia (IMT) is a sporadic cause of thrombocytopenia in horses for which it is difficult to establish a definitive diagnosis. In this report, we describe 3 horses with severe thrombocytopenia in which flow cytometric analysis of platelets for surface-bound IgG was used in an attempt to substantiate a provisional diagnosis of IMT. A distinct proportion (4.28%, 5.04%, and 7.95%) of platelets with surface-bound IgG was detected in the 3 thrombocytopenic horses, but not in 6 healthy horses (0.03% to 0.15%) or 6 horses with colic (0.00% to 1.21%). These results, in conjunction with elimination of other potential causes of the thrombocytopenia, established a diagnosis of IMT. The horses were treated with glucocorticoids alone or in combination with azathioprine, and the thrombocytopenia gradually resolved. Flow cytometric detection of platelet-bound IgG was readily performed and may be a useful adjunct for the diagnosis of IMT.
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Affiliation(s)
- M Kimberley J McGurrin
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada
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