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Boutari C, Zarkada E, Vyzantiadis A, Vlachaki E, Mantzou G, Karipidou C, Theodoridou S. A Hematoma in the Anterior Abdominal Muscle in a Woman Receiving Venlafaxine: A Literature Review of the Reports on Similar Cases. Acta Haematol 2024:1-6. [PMID: 38631301 DOI: 10.1159/000538652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Venlafaxine (VEN) is a selective norepinephrine reuptake inhibitor (SNRI) that mainly helps treat major depressive disorder and anxiety and panic disorders. It works by inhibiting the reuptake of serotonin (5-hydroxytryptamine, 5-HT) and noradrenaline (NA) by presynaptic neurons. Additionally, VEN administration has been linked with a bleeding predisposition that may be due to the inhibition of NA and 5-HT uptake by platelets which have their own receptors on their surface and are implicated in platelet aggregation. CASE PRESENTATION Herein, we report a case of a 54-year-old patient treated with VEN, who presented with a hematoma in the anterior abdominal muscle. We also present the observational studies and case reports highlighting the association of SNRIs use with various hemorrhagic complications ranging from gastrointestinal hemorrhage or vaginal bleeding to bleeding during or after surgery due to either thrombocytopenia or impaired platelet aggregation. CONCLUSION Given the cases of either reductions in the platelet count or impairment of platelet activity accompanied by bleeding events, every clinician should be aware of these possible adverse effects when prescribing SNRIs.
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Affiliation(s)
- Chrysoula Boutari
- Blood Bank Center, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
- Department of Internal Medicine, Aristotle University of Thessaloniki, Hippocration General Hospital, Thessaloniki, Greece
| | - Evangelia Zarkada
- Blood Bank Center, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | | | - Efthymia Vlachaki
- Adult Thalassemia Unit, 2nd Department of Internal Medicine, Aristotle University of Thessaloniki, Hippocration General Hospital, Thessaloniki, Greece
| | - Genovefa Mantzou
- Blood Bank Center, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Cristine Karipidou
- Blood Bank Center, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Stamatia Theodoridou
- Blood Bank Center, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
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Wang X, Feng T, Wang C, Li J, Ge Y, Zhai X, Wang H, Zeng M. Safety of Immunization for Children with Immune Thrombocytopenia. Vaccines (Basel) 2024; 12:66. [PMID: 38250879 PMCID: PMC10820612 DOI: 10.3390/vaccines12010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Vaccine hesitancy is a common issue for children with immune thrombocytopenia (ITP) in China. The objective of this paper is to assess the immunization statuses of children with ITP, analyze the possible relationship between immunization and thrombocytopenia, and evaluate the safety of immunization after ITP remission. We included 186 children with an ITP history and followed up with them for two years after receiving re-immunization recommendations. The participants had an overall age-appropriate vaccine coverage of 57.9%. Vaccine-associated thrombocytopenia occurred in 99 (53.2%, 95% CI = 46.06-60.26) children ranging from 0 to 34 days following immunization, with 14 vaccines involved. One hundred and fifty-four (82.3%, 95% CI = 76.72-87.54) children were advised to restart immunization, whereas 32 (17.2%, 95% CI = 12.46-23.28) were advised to postpone partial or full vaccination. Following the follow-up, 150 (80.6%, 95% CI = 74.37-85.68) children completed the catch-up immunization, whereas 27 (14.5%, 95% CI = 10.17-20.30) partially completed it. Four patients with thrombocytopenia relapsed following the re-immunization. Incomplete catch-up immunization was related to the factors of chronic thrombocytopenia, vaccine-associated thrombocytopenia, and the relapse of ITP following re-immunization. ITP may occur after immunization with vaccines other than measles-containing vaccines. Re-immunization in children with ITP generally does not result in a relapse, regardless of whether the previous thrombocytopenia was vaccine-associated.
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Affiliation(s)
- Xiangshi Wang
- Department of Infectious Disease, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China; (X.W.)
| | - Tianxing Feng
- Department of Pediatrics, Shanghai Clinical Research and Trial Center, Shanghai 201203, China;
| | - Chuning Wang
- Department of Infectious Disease, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China; (X.W.)
| | - Jingjing Li
- Department of Infectious Disease, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China; (X.W.)
| | - Yanling Ge
- Department of Infectious Disease, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China; (X.W.)
| | - Xiaowen Zhai
- Department of Hematology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China;
| | - Hongsheng Wang
- Department of Hematology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China;
| | - Mei Zeng
- Department of Infectious Disease, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 201102, China; (X.W.)
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Pande A, Kumar A, Krishnani H, Acharya S, Shukla S. Recent Advances in the Management of Microangiopathic Hemolytic Anemias (MAHA): A Narrative Review. Cureus 2023; 15:e47196. [PMID: 38021690 PMCID: PMC10653637 DOI: 10.7759/cureus.47196] [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] [Received: 08/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Red blood cells (RBCs) start to break down early in hemolytic anemia, which can be chronic or life-threatening. It should be considered while determining if normocytic or macrocytic anemia is present. Hemolysis in the reticuloendothelial system may happen intravascularly, extravascularly, or both. It accounts for a broad spectrum of laboratory and clinical situations, both physiological and pathological. Whenever the frequency of RBC breakdown is rapid enough to lower hemoglobin levels below the normal range, hemolytic anemia occurs. Microangiopathic hemolytic anemia (MAHA) is a term used to describe non-immune hemolysis induced by intravascular RBC fragmentation caused by substances in the tiny blood arteries that generate schistocytes in the peripheral circulation. Microvasculature abnormalities, such as small arterioles and capillaries, are usually involved. Furthermore, MAHA can also be brought on by intravascular devices like a prosthetic heart valve or assistive technologies. Poor deformity results in entrapment, phagocytosis, antibody-mediated elimination through phagocytosis or direct complement activation, fragmentation brought about by microthrombi or acute mechanical stress, oxidation, or spontaneous cellular death. Hemolysis may cause acute anemia, jaundice, hematuria, dyspnea, tiredness, tachycardia, and possibly hypotension. This article aims to synthesize existing research, identify therapeutic strategies, and provide insights into current and emerging approaches for managing this complex hematological disorder.
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Affiliation(s)
- Arundhati Pande
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhishek Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshil Krishnani
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Samarth Shukla
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Lubnow M, Berger J, Schneckenpointner R, Zeman F, Lunz D, Philipp A, Foltan M, Lehle K, Heimerl S, Hart C, Schmid C, Fisser C, Müller T. Prevalence and outcomes of patients developing heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. PLoS One 2022; 17:e0272577. [PMID: 35939484 PMCID: PMC9359525 DOI: 10.1371/journal.pone.0272577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/21/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives Unfractionated heparin (UFH) is the commonly used anticoagulant to prevent clotting of the ECMO circuit and thrombosis of the cannulated vessels. A side effect of UFH is heparin-induced thrombocytopenia (HIT). Little is known about HIT during ECMO and the impact of changing anticoagulation in ECMO patients with newly diagnosed HIT. The aim of the study was to determine the prevalence, complications, impact of switching anticoagulation to argatroban and outcomes of patients developing heparin-induced thrombocytopenia (HIT) during either veno-venous (VV) or veno-arterial (VA) ECMO. Methods Retrospective observational single centre study of prospectively collected data of consecutive patients receiving VV ECMO therapy for severe respiratory failure and VA ECMO for circulatory failure from January 2006 to December 2016 of the Medical intensive care unit (ICU) of the University Hospital of Regensburg. Treatment of HIT on ECMO was done with argatroban. Results 507 patients requiring ECMO were included. Further HIT-diagnostic was conducted if HIT-4T-score was ≥4. The HIT-confirmed group had positive HIT-enzyme-linked-immunosorbent-assay (ELISA) and positive heparin-induced-platelet-activation (HIPA) test, the HIT-suspicion group a positive HIT-ELISA and missing HIPA but remained on alternative anticoagulation until discharge and the HIT-excluded group a negative or positive HIT-ELISA, however negative HIPA. These were compared to group ECMO-control without any HIT suspicion. The prevalence of HIT-confirmed was 3.2%, of HIT-suspicion 2.0% and HIT-excluded 10.8%. Confirmed HIT was trendwise more frequent in VV than in VA (3.9 vs. 1.7% p = 0.173). Compared to the ECMO control group, patients with confirmed HIT were longer on ECMO (median 13 vs. 8 days, p = 0.002). Different types of complications were higher in the HIT-confirmed than in the ECMO-control group, but in-hospital mortality was not different (31% vs. 41%, p = 0.804). Conclusion HIT is rare on ECMO, should be suspected, if platelets are decreasing, but seems not to increase mortality if treated promptly.
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Affiliation(s)
- Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
- * E-mail:
| | - Johannes Berger
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Roland Schneckenpointner
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Bavaria, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Susanne Heimerl
- Department of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christina Hart
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
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Smolarczyk-Kosowska J, Kosowski M, Kunert Ł, Filipczyk K, Wojciechowski M, Piegza M, Gorczyca P, Okopień B, Pudlo R. Impact of Venlafaxine on Platelet Count and Activity—Case Report and Narrative Review. Medicina (B Aires) 2022; 58:medicina58050626. [PMID: 35630043 PMCID: PMC9145928 DOI: 10.3390/medicina58050626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
Venlafaxine (VEN) is considered to be one of the most effective antidepressants. It belongs to the group of serotonin (5-HT) and noradrenaline (NA) reuptake inhibitors (SNRIs). NA and 5-HT have receptors on the surface of platelets and are involved in platelet aggregation. In this case study, we present the case of a patient treated for one of the types of myeloproliferative neoplasm (MPN), essential thrombocythemia (ET), in whom VEN was added to pharmacotherapy during the treatment of a severe episode of depression with psychotic symptoms. We observed a gradual reduction in platelet count when increasing the dose of VEN. We also present a narrative review of literature about the effect of VEN on platelet counts and activity. We conclude that, in the group of patients taking VEN, attention should be paid to the rare adverse effect of a decrease in the number of platelets.
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Affiliation(s)
- Joanna Smolarczyk-Kosowska
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
- Correspondence:
| | - Michał Kosowski
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland; (M.K.); (B.O.)
| | - Łukasz Kunert
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
| | - Karolina Filipczyk
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
| | - Marcin Wojciechowski
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
| | - Magdalena Piegza
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
| | - Piotr Gorczyca
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
| | - Bogusław Okopień
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland; (M.K.); (B.O.)
| | - Robert Pudlo
- Department of Psychiatry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.K.); (K.F.); (M.W.); (M.P.); (P.G.); (R.P.)
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Gold Nanoparticles: Multifaceted Roles in the Management of Autoimmune Disorders. Biomolecules 2021; 11:biom11091289. [PMID: 34572503 PMCID: PMC8470500 DOI: 10.3390/biom11091289] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/12/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Gold nanoparticles (GNPs) have been recently applied for various diagnostic and therapeutic purposes. The unique properties of these nanoparticles (NPs), such as relative ease of synthesis in various sizes, shapes and charges, stability, high drug-loading capacity and relative availability for modification accompanied by non-cytotoxicity and biocompatibility, make them an ideal field of research in bio-nanotechnology. Moreover, their potential to alleviate various inflammatory factors, nitrite species, and reactive oxygen production and the capacity to deliver therapeutic agents has attracted attention for further studies in inflammatory and autoimmune disorders. Furthermore, the characteristics of GNPs and surface modification can modulate their toxicity, biodistribution, biocompatibility, and effects. This review discusses in vitro and in vivo effects of GNPs and their functionalized forms in managing various autoimmune disorders (Ads) such as rheumatoid arthritis, type 1 diabetes, and multiple sclerosis.
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Moore J, Baer MR, Grover BE, Aster RH, Millstein LS. Moxifloxacin-Induced Thrombocytopenia Mediated by Moxifloxacin-Dependent IgM and IgG Antiplatelet Antibodies: A Case Report. Cureus 2020; 12:e10507. [PMID: 33094048 PMCID: PMC7571590 DOI: 10.7759/cureus.10507] [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: 11/21/2022] Open
Abstract
Moxifloxacin is a rare but important cause of drug-induced immune thrombocytopenia (DIT). We describe a patient who presented with an acute onset of severe thrombocytopenia complicated by petechial rash, epistaxis, and melena. Recent new drug exposures included moxifloxacin and two proton pump inhibitors. On presentation to the hospital, all recently initiated medications were discontinued and the patient’s thrombocytopenia was treated with platelet transfusions, intravenous immunoglobulin, and high-dose corticosteroids. Her thrombocytopenia improved over the next seven days and she was discharged on hospital day 8. Serologic testing revealed strongly positive moxifloxacin-dependent IgM and IgG antiplatelet antibodies, confirming a diagnosis of moxifloxacin-induced immune thrombocytopenia. DIT has been reported with other fluoroquinolone antibiotics, especially ciprofloxacin. This case documents a rare but potentially fatal complication of exposure to moxifloxacin and is the first to demonstrate objective evidence of acute sensitization with IgM antibody positivity. It highlights the need to consider this potential reaction when choosing antibiotic therapy, particularly in patients who are at high risk for bleeding, have hematologic disorders, or are receiving myelosuppressive therapies, and perhaps in those with a history of multiple drug allergies.
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Affiliation(s)
- Joel Moore
- Departments of Medicine and Pediatrics, University of Maryland School of Medicine, Baltimore, USA
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Brian E Grover
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, USA
| | - Richard H Aster
- Department of Medicine/Research, Versiti-Blood Research Institute, Milwaukee, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Leah S Millstein
- Departments of Medicine and Pediatrics, University of Maryland School of Medicine, Baltimore, USA
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Abstract
Platelets, or megakaryocytes, are irregular, disk-shaped cell fragments circulating in the blood. They are a primary component in maintaining hemostasis. Low platelet counts, or thrombocytopenia, leave patients at an increased risk of hemorrhage. This article discusses various etiologies of disorders of low platelets and current therapies for management.
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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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Jatzlauk G, Althaus K, Strobel U, Kiefel V, Wesche J, Muehlenberg K, Greinacher A, Bakchoul T. Flucloxacillin-induced immune thrombocytopenia. Transfusion 2015; 56:67-72. [DOI: 10.1111/trf.13284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/17/2015] [Accepted: 07/22/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Gregor Jatzlauk
- Institut for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Karina Althaus
- Institut for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Ulrike Strobel
- Institut for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Volker Kiefel
- Institute for Transfusion Medicine; Universitätsmedizin Rostock; Rostock, Germany
| | - Jan Wesche
- Institut for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Klaus Muehlenberg
- Klinik für Gastroenterologie und Interventionelle Endoskopie; Krankenhaus Barmherzige Brüder; Regensburg Germany
| | - Andreas Greinacher
- Institut for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - Tamam Bakchoul
- Institut for Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
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Abstract
Heparin is widely used for the prevention and treatment of thrombotic and particularly cardiovascular disorders. Unfortunately, 0.5 to 3.0% of patients given heparin develop an immune reaction, commonly termed Type II heparin-induced thrombocytopenia (HIT). This is characterized by a moderate thrombocytopenia and in some patients, a venous or arterial thrombosis. This frequently leads to disastrous sequelae, such as limb amputation and death. The pathophysiological basis of this serious adverse drug reaction is the production of an immunoglobulin G antibody that reacts with an antigenic complex consisting of heparin and platelet factor 4. A significant risk factor for the development of HIT is recent surgery, and the frequency of developing an antiheparin-platelet factor 4 or HIT antibody is particularly high in cardiac surgery patients, although surprisingly, only a few of these patients actually develop the clinical syndrome of HIT. This review will discuss the frequency, pathophysiology, clinical features, diagnosis and management of HIT.
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Affiliation(s)
- Beng H Chong
- Department of Medicine, St George Clinical School and Centre of Vascular Research, University of New South Wales, Sydney, New South Wales, USA.
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Hron G, Knutson F, Thiele T, Althaus K, Busemann C, Friesecke S, Greinacher A, Lubenow N. Alternative diagnosis to heparin-induced thrombocytopenia in two critically ill patients despite a positive PF4/heparin-antibody test. Ups J Med Sci 2013; 118:279-84. [PMID: 24102149 PMCID: PMC4190887 DOI: 10.3109/03009734.2013.838811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Thrombocytopenia can cause diagnostic challenges in patients who have received heparin. Heparin-induced thrombocytopenia (HIT) is often considered in the differential diagnosis, and a positive screening can be mistaken as confirmation of the disorder. We present two patients who both received low-molecular-weight heparin for several days. In the first patient, clinical judgment rejected the suspicion of HIT despite a positive screening assay, and treatment for the alternative diagnosis of post-transfusion purpura was correctly initiated. In the second patient, the inaccurate diagnosis HIT was pursued due to a positive screening assay, while the alternative diagnosis of drug-dependent thrombocytopenia caused by piperacillin/tazobactam was rejected. This resulted in re-exposure to piperacillin/tazobactam which caused a second episode of severe thrombocytopenia. A positive screening assay for platelet factor 4/heparin-antibody should be verified by a functional assay, especially in patients with low pretest probability for HIT.
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Affiliation(s)
- Gregor Hron
- Abteilung für Transfusionsmedizin, Institut für Immunologie und Transfusionsemedizin, Ernst-Moritz-Arndt University Greifswald, Germany
| | - Folke Knutson
- Department of Clinical Immunology and Transfusion Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Thomas Thiele
- Abteilung für Transfusionsmedizin, Institut für Immunologie und Transfusionsemedizin, Ernst-Moritz-Arndt University Greifswald, Germany
| | - Karina Althaus
- Abteilung für Transfusionsmedizin, Institut für Immunologie und Transfusionsemedizin, Ernst-Moritz-Arndt University Greifswald, Germany
| | - Christoph Busemann
- Klinik für Innere Medizin C, Ernst-Moritz-Arndt University Greifswald, Germany
| | - Sigrun Friesecke
- Klinik für Innere Medizin B, Ernst-Moritz-Arndt University Greifswald, Germany
| | - Andreas Greinacher
- Abteilung für Transfusionsmedizin, Institut für Immunologie und Transfusionsemedizin, Ernst-Moritz-Arndt University Greifswald, Germany
| | - Norbert Lubenow
- Department of Clinical Immunology and Transfusion Medicine, Uppsala University Hospital, Uppsala, Sweden
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Abstract
Immune thrombocytopenia has been attributed to many causes. Several drugs have been implicated as culprits in causing drug-induced thrombocytopenia. Although the mechanism for this type of thrombocytopenia is not well understood, at least three types of antibodies appear to be involved: drug-dependent antibodies, hapten-dependent antibodies, and drug-induced platelet-reactive autoantibodies. In this report, we describe a case in which furosemide was identified as the probable cause of drug-induced thrombocytopenia in an 84-year-old man with chronic symptomatic idiopathic thrombocytopenia for seven years before discovery. The patient's platelet count and daily furosemide dose, both intravenous and oral, were documented throughout his medical history. A dose-dependent change in platelet count was observed in association with the furosemide dose. His platelet count increased on discontinuation of furosemide and beginning of torsemide. Several months after discontinuation of furosemide, his platelet count increased to a 9-year high of 206 × 10³/mm³ from a low of 36 × 10³/mm³ while receiving furosemide therapy. Based on the observations of this case report, clinicians should more readily consider furosemide as a potential cause of thrombocytopenia.
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Affiliation(s)
- Pamella S Ochoa
- School of Pharmacy, Texas Tech University Health Sciences Center, Abilene, Texas 79601, USA.
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Song HR, Jung YE, Wang HR, Woo YS, Jun TY, Bahk WM. Platelet count alterations associated with escitalopram, venlafaxine and bupropion in depressive patients. Psychiatry Clin Neurosci 2012; 66:457-9. [PMID: 22834666 DOI: 10.1111/j.1440-1819.2012.02355.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The objective of the present study was to evaluate changes in platelet counts on three different kinds of antidepressant. All subjects (n = 131) in their drug-naïve state had been diagnosed with depression. Escitalopram (n = 42), venlafaxine (n = 50) and bupropion (n = 39) were prescribed, and platelet count was measured before and after 1 month of treatment and compared. Decrease in platelet count on escitalopram was significant, while the others were not. These findings suggest that escitalopram may be associated with decreased platelet count, and bupropion is less likely to exert an influence on platelet count.
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Affiliation(s)
- Hoo Rim Song
- Department of Psychiatry, Yeouido St Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
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17
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Anand A, Chauhan HKC. Piperacillin and vancomycin induced severe thrombocytopenia in a hospitalized patient. Platelets 2011; 22:294-301. [PMID: 21309645 DOI: 10.3109/09537104.2010.549973] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In hospitalized patients with complex medical problems on numerous drugs, thrombocytopenia may have a multiple confounding etiology. Keeping this in mind, it is of utmost importance to monitor the platelet count regularly during hospitalization and on subsequent follow-up visits, even after the most probable etiology has been identified/most likely causative drug has been withdrawn. Isolated thrombocytopenia with no evidence of microangiopathic hemolysis on the peripheral blood smear in an acutely ill hospitalized patient implicated sepsis, disseminated intravascular coagulation and drugs as the most probable causes. Our patient represents an uncommon case of antibiotic-induced severe immune thrombocytopenia, as he developed both vancomycin-dependent and piperacillin-dependent antibodies, while being treated for cellulitis (vancomycin-specific antibodies of the IgG isotype, and both IgG and IgM antibodies specific for piperacillin were identified in laboratory testing). Vancomycin was stopped before the reports were available. Following this, the patient's platelet count showed a transient upward trend, but then the thrombocytopenia worsened drastically reaching a nadir of 10,000/µL. The platelet count returned to normal only after piperacillin/tazobactam was stopped after a week, thus establishing it as the cause of the more severe thrombocytopenia, which occurred later on; this was subsequently confirmed by the laboratory results. Vancomycin is an established cause of drug-induced immune thrombocytopenias, especially in acutely ill, hospitalized or elderly patients, whereas incidents of piperacillin/tazobactam-induced immune thrombocytopenia are uncommon. In case clinical suspicion is high, workup should include immunoprecipitation and flow cytometry studies to confirm antiplatelet antibodies.
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18
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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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19
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Abstract
Primary immune thrombocytopenic purpura (ITP) remains a diagnosis of exclusion both from nonimmune causes of thrombocytopenia and immune thrombocytopenia that develops in the context of other disorders (secondary immune thrombocytopenia). The pathobiology, natural history, and response to therapy of the diverse causes of secondary ITP differ from each other and from primary ITP, so accurate diagnosis is essential. Immune thrombocytopenia can be secondary to medications or to a concurrent disease, such as an autoimmune condition (eg, systemic lupus erythematosus [SLE], antiphospholipid antibody syndrome [APS], immune thyroid disease, or Evans syndrome), a lymphoproliferative disease (eg, chronic lymphocytic leukemia or large granular T-lymphocyte lymphocytic leukemia), or chronic infection, eg, with Helicobacter pylori, human immunodeficiency virus (HIV), or hepatitis C virus (HCV). Response to infection may generate antibodies that cross-react with platelet antigens (HIV, H pylori) or immune complexes that bind to platelet Fcγ receptors (HCV), and platelet production may be impaired by infection of megakaryocyte (MK) bone marrow–dependent progenitor cells (HCV and HIV), decreased production of thrombopoietin (TPO), and splenic sequestration of platelets secondary to portal hypertension (HCV). Sudden and severe onset of thrombocytopenia has been observed in children after vaccination for measles, mumps, and rubella or natural viral infections, including Epstein-Barr virus, cytomegalovirus, and varicella zoster virus. This thrombocytopenia may be caused by cross-reacting antibodies and closely mimics acute ITP of childhood. Proper diagnosis and treatment of the underlying disorder, where necessary, play an important role in patient management.
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Affiliation(s)
- Douglas B Cines
- University of Pennsylvania School of Medicine, Department of Pathology and Laboratory Medicine, Philadelphia, PA 19104, USA.
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20
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Abstract
Esophageal variceal bleeding can be serious or life threatening. Drug-induced thrombocytopenia can further complicate such bleeding episodes. Thrombocytopenia because of sandostatin has been reported in the literature only once previously. We describe a case of sandostatin-induced reversible thrombocytopenia with a positive rechallenge. Platelet count decreased during administration of sandostatin and recovered only when the infusion was halted. The proposed mechanism of thrombocytopenia during both episodes is immunologic. Physician awareness of sandostatin-induced thrombocytopenia can prevent unnecessary complication during episodes of esophageal variceal bleeding and is rapidly reversed with discontinuation of the drug.
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21
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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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22
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Kenney B, Stack G. Drug-induced thrombocytopenia. Arch Pathol Lab Med 2009; 133:309-14. [PMID: 19195976 DOI: 10.5858/133.2.309] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2008] [Indexed: 11/06/2022]
Abstract
Drug-induced thrombocytopenia was first described in the 19th century, yet our understanding of its pathogenesis continues to evolve. The list of drugs implicated in drug-induced thrombocytopenia is extensive and growing. Many, if not most, of these medications induce thrombocytopenia by immune mechanisms. Because the degree of thrombocytopenia can put patients at risk for serious bleeding, a prompt diagnosis is key to clinical management. The laboratory approach to diagnosing drug-induced thrombocytopenia is 2-pronged. First, nondrug causes of thrombocytopenia must be ruled out. Second, testing for drug-dependent platelet antibodies, available at specialized reference laboratories, often can identify the offending medication, although usually not in time for initial clinical management. Once a medication is suspected of causing thrombocytopenia, it must be discontinued promptly, and the patient should be monitored closely. Thrombocytopenia generally resolves quickly after offending medication withdrawal, and the prognosis of drug-induced thrombocytopenia is then excellent.
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Affiliation(s)
- Barton Kenney
- Department of Laboratory Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06512, USA.
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23
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Bühler R, Mattle HP. Hematological diseases and stroke. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:887-934. [PMID: 18804686 DOI: 10.1016/s0072-9752(08)93045-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Robert Bühler
- Department of Neurology, Iselspital, University of Bern, Bern, Switzerland
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24
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Anesthetic implications of the new anticoagulant and antiplatelet drugs. J Clin Anesth 2008; 20:228-37. [DOI: 10.1016/j.jclinane.2007.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Revised: 09/16/2007] [Accepted: 10/26/2007] [Indexed: 01/29/2023]
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25
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Havarinasab S, Johansson U, Pollard KM, Hultman P. Gold causes genetically determined autoimmune and immunostimulatory responses in mice. Clin Exp Immunol 2007; 150:179-88. [PMID: 17680821 PMCID: PMC2219286 DOI: 10.1111/j.1365-2249.2007.03469.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Natrium aurothiomaleate (GSTM) is a useful disease-modifying anti-rheumatic drug, but causes a variety of immune-mediated adverse effects in many patients. A murine model was used to study further the interaction of GSTM with the immune system, including induction of systemic autoimmunity. Mice were given weekly intramuscular injections of GSTM and controls equimolar amounts of sodium thiomaleate. The effects of gold on lymphocyte subpopulations were determined by flow cytometry. Humoral autoimmunity was measured by indirect immunofluorescence and immunoblotting, and deposition of immunoglobulin and C3 used to assess immunopathology. Gold, in the form of GSTM, stimulated the murine immune system causing strain-dependent lymphoproliferation and autoimmunity, including a major histocompatibility complex (MHC)-restricted autoantibody response against the nucleolar protein fibrillarin. GSTM did not cause glomerular or vessel wall IgG deposits. However, it did elicit a strong B cell-stimulating effect, including both T helper 1 (Th1)- and Th2-dependent isotypes. All these effects on the immune system were dependent on the MHC genotype, emphasizing the clinical observations of a strong genetic linkage for the major adverse immune reactions seen with GSTM treatment.
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Affiliation(s)
- S Havarinasab
- Department of Clinical and Experimental Medicine, Molecular and Immunological Pathology, Linköping University, Linköping, Sweden
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26
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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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27
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Gettings EM, Brush KA, Van Cott EM, Hurford WE. Outcome of postoperative critically ill patients with heparin-induced thrombocytopenia: an observational retrospective case-control study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R161. [PMID: 17109753 PMCID: PMC1794468 DOI: 10.1186/cc5100] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 11/07/2006] [Accepted: 11/16/2006] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is described as a decrease in platelet count associated with heparin administration and is an immune-mediated adverse drug reaction that can cause both arterial and venous thromboses. It can be a life-threatening complication of heparin exposure. Little data concerning incidence, predisposing factors, or outcome in critically ill surgical patients are available. METHODS All critically ill, postoperative patients admitted between January 1, 2000, and December 31, 2001, to a surgical intensive care unit (SICU) who tested positive by an enzyme-linked immunosorbent assay for the HIT antibody (HPIA; Diagnostica Stago, Inc., Parsippany, NJ, USA) were identified. Patient risk factors and outcomes were abstracted retrospectively from the medical record and compared with those from control patients matched for age, gender, diagnosis, severity of illness, and date of SICU admission. RESULTS Two hundred and ten patients out of 2,046 patients (10%) admitted to the SICU had HIT assays performed. Nineteen patients (0.9% of admissions; 9% of tested individuals) had positive tests. HIT-antibody-positive patients, compared with 19 matched controls, had an increased risk of death or major thrombotic complications (37% versus 10%; P < 0.05) and prolonged length of intensive care unit (ICU) stay (20 days versus 10 days; P < 0.05). Exposure to heparin via intravascular flushes alone was sufficient to generate HIT antibodies in 12 of 19 (63%) patients. Five patients received platelet transfusions after the diagnosis of HIT was known; four of these patients died. CONCLUSION Heparin flushes were the most common cause of HIT in this study. HIT-antibody-positive patients had an increased risk of death or major complications and a prolonged length of ICU stay. Platelet transfusions often were administered despite a positive HIT test result and were associated with a high mortality rate. Treatment algorithms that minimize exposure to heparin and contraindicate platelet transfusions merit further study.
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Affiliation(s)
- Elise M Gettings
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Kathryn A Brush
- Department of Nursing, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Elizabeth M Van Cott
- Department of Clinical Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William E Hurford
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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28
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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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29
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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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30
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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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31
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Invited Commentary. World J Surg 2005. [DOI: 10.1007/s00268-005-1101-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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32
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Abstract
Cardiac surgery using cardiopulmonary bypass (CPB) provokes a systemic inflammatory response. This is mainly triggered by contact activation of blood by artificial surfaces of the extracorporeal circuit. Although often remaining sub-clinical and resolving promptly at the end of CPB, in its most extreme form this inflammatory response may be associated with the development of the systemic inflammatory response syndrome (SIRS) that can often lead to major organ dysfunction (MODs) and death. Here, we review the pathophysiology behind the development of this "whole body" inflammatory response and some of the methods currently used to minimise it.
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Affiliation(s)
- J R S Day
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Du Cane road, London W12 0HS, UK.
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33
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Ohmori T, Nishii K, Hagihara A, Takeda M, Sekido K. Acute thrombocytopenia induced by jui, a traditional herbal medicine. J Thromb Haemost 2004; 2:1479-80. [PMID: 15304064 DOI: 10.1111/j.1538-7836.2004.00786.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Melis E, Bonnefoy A, Daenens K, Yamamoto H, Vermylen J, Hoylaerts MF. alphaIIbbeta3 antagonism vs. antiadhesive treatment to prevent platelet interactions with vascular subendothelium. J Thromb Haemost 2004; 2:993-1002. [PMID: 15140136 DOI: 10.1111/j.1538-7836.2004.00747.x] [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: 11/28/2022]
Abstract
Platelets adhering to blood vessels promote coagulation and inflammation, and release growth factors that trigger smooth muscle cell activation. We have therefore studied the pharmacological modification of platelet deposition quantitatively by comparing adhesion of flowing platelets to various subendothelial ligands in the absence or presence of an antialpha(IIb)beta(3) antagonist with the effects of antiadhesive treatment consisting of von Willebrand factor (VWF) and fibronectin neutralization or of the combined inhibition of platelet adhesion and aggregation. In vitro, perfusion of anticoagulated human blood over calf skin collagen reiterated that alpha(IIb)beta(3) antagonism prevents platelet aggregation, but not adhesion per se: single platelets strongly bound to collagen at wall shear rates of both 1300 and 2700 s(-1), largely VWF-independent. When perfused over a human umbilical vein endothelial cell-derived extracellular matrix, single alpha(IIb)beta(3)-antagonized platelets primarily adhered to matrix-bound VWF when perfused at 2700 s(-1), but at 1300 s(-1) they also adhered significantly to fibronectin. During perfusion of anticoagulated rabbit blood over de-endothelialized rabbit aorta at a wall shear rate of 1100 s(-1), alpha(IIb)beta(3) antagonism even increased the absolute numbers of adhering platelets and VWF neutralization redirected alpha(IIb)beta(3)-antagonized platelets towards other vascular ligands. Finally, in vivo, following photochemically induced blood vessel injury in mice, alpha(IIb)beta(3) antagonism inhibited platelet-rich thrombus formation, but platelet adhesion was only significantly inhibited when associated with fibronectin neutralization. In conclusion, antiadhesive platelet treatment more potently interferes with platelet deposition on injured blood vessels than alpha(IIb)beta(3) antagonism, but abrogating platelet adhesion can only be achieved by carefully selected antiplatelet drug combinations.
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Affiliation(s)
- E Melis
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
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35
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Affiliation(s)
- Jonathan R S Day
- Department of Cardiac Surgery, Hammersmith Hospital London, United Kingdom.
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36
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Liu X, Sahud MA. Glycoprotein IIb/IIIa complex is the target in mirtazapine-induced immune thrombocytopenia. Blood Cells Mol Dis 2003; 30:241-5. [PMID: 12737939 DOI: 10.1016/s1079-9796(03)00037-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Mirtazapine (MW 265.36), a tetracyclic antidepressant of the piperazine-azapine group which augments central noradrenergic and serotonergic activity, is currently used as an oral antidepressant. We report a case of severe thrombocytopenia in a 66-year-old patient occurring after mirtazapine administration, suggesting an immune mechanism. This report documents the first case of mirtazapine-induced immune thrombocytopenia. The patient's serum was screened for drug-induced anti-platelet antibody with the chromium(51) (Cr(51)) platelet lysis technique. The drug-dependent antibody was characterized using flow cytometry, the monoclonal antibody immobilization of platelet antigens assay (MAIPA assay), and immunoprecipitation. By the Cr(51) platelet lysis technique, we obtained an equivocal result for the detection of mirtazapine-induced antibody. However, the patient's serum tested positive for mirtazapine-induced antibody by flow cytometry. The results showed that the binding ratio of 5.7 (mean fluorescence intensity) in the presence of the patient's serum and mirtazapine in a final concentration of 1.0 mmol/L was strongly positive. The antibody was found to bind the glycoprotein (GP) IIb/IIIa complex by MAIPA assay by using five different monoclonal antibodies against GP complexes Ib/IX, GPIIb/IIIa, or GPIa/IIa. Immunoprecipitation studies showed that the GPIIb/IIIa complex was precipitated by antibody in the presence, but not in the absence, of mirtazapine. These findings provide evidence that immune thrombocytopenia can be caused by sensitivity to the antidepressant mirtazapine. This is the first well-documented case of mirtazapine-induced immune thrombocytopenia.
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Affiliation(s)
- Xiaojing Liu
- Blood Research Institute and Coagulation Center, Oakland, CA 94609, USA
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