First Report of Eltrombopag Induced Severe Autoimmune Hemolytic Anemia in the Management of Waldenström Macroglobulinemia-associated Autoimmune Thrombocytopenia

Background: Autoimmune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) can be observed in Waldenström Macroglobulinemia (WM). The cause of AIHA should be carefully distinguished during the disease management. Case Presentation: A 63-year-old female WM patient complicated with thrombocytopenia, who was admitted to our department with a complaint of abdominal pain. After first half of bortezomib/dexamethasone/rituximab (BRD) chemotherapy, her platelet level recovered, but subsequently decreased to extremely low level (around 1-2×109/L), and the patient suffered from platelet transfusion refractoriness. During the management of refractory thrombocytopenia, the patient developed severe hemolytic anemia, and further tests confirmed warm AIHA. FcγRIIα polymorphism test showed that the patient had FcγRIIα-131RH, which implied that the AIHA may not be WM-related. Given the effects of ibrutinib in controlling WM, ibrutinib single treatment was started, which quickly corrected the thrombocytopenia within five days, but not hemolysis. With a relatively safe platelet level, eltrombopag was stopped, and the hemolysis alleviated within three days after eltrombopag withdrawal. Conclusion: This is the first report on eltrombopag-induced AIHA, and we should always keep in mind of the drug induced hemolysis even in disorders with autoimmune background.

Epidemiological Study and Analysis of Risk Factors for Elizabethkingia Meningoseptica Infection in a Large General Hospital in China

Background As a kind of nosocomial infection pathogen which can cause high mortality, its susceptibility and death risk factors are still unclear. Aim To analyze the epidemiological characteristics of and risk factors for Elizabethkingia meningoseptica infection. Methods Relevant literature from 2011 to 2019 with the key words “E. meningoseptica” or “Elizabethkingia meningoseptica” in the title and abstract was retrieved from the PubMed database. The risk factors of infection and death for infected patients treated at Southwest Hospital during the above period were analyzed by logistic regression. Results From 2011 to 2019, 366 patients infected with E. meningoseptica were reported in 132 articles in the PubMed database. The mortality rate was 63.20%. During the same period, 92 infected patients were treated at our hospital. The overall mortality rate was approximately 28.3% (26/92) to 39.1% (36/92). The resistance rate for carbapenems was 100%; for cephalosporins, it was more than 90%; and for minocycline, it was 0. Central venous catheterization (p < 0.001), mechanical ventilation (p = 0.015), bacteria type (p < 0.001), operation type (p = 0.001), fungal infection (p < 0.001), carbapenem use (p = 0.000), and triazole use (p = 0.016) were independent risk factors for E. meningoseptica infection. According to logistic regression, bacteria type (p = 0.037), platelet level (p = 0.014), and mechanical ventilation (p = 0.043) were risk factors for death. Conclusion The incidence of E. meningoseptica infection worldwide shows a trend toward increasing yearly. Invasive operations, multiple bacterial or fungal infections and the use of carbapenems may be predisposing factors, and platelet level, bacteria type, and mechanical ventilation were risk factors for death.

A Case of Epistaxis as the First Sign of Acute Idiopathic Thrombocytopenic Purpura

Idiopathic thrombocytopenic purpura (ITP) is an acquired thrombocytopenia caused by the action of autoantibodies against platelet antigens. It is traditionally defined by a platelet count of less than 10 × 104/μL. Most patients with ITP are asymptomatic; however, symptoms have been confirmed in some cases. Conversely, it is very rare to find epistaxis as the first sign of ITP. We report the case of an 84-year-old man who came to the ear, nose, and throat department with severe and repeated epistaxis. We decided to keep him hospitalized as it was very difficult to stop the nasal bleeding. A full blood count showed a platelet level of only 1000/μL. Hematologic results confirmed the diagnosis of ITP. The patient underwent treatment with intravenous gamma-globulin, platelet transfusions, and romiplostim with a favorable response.

Comparison of Platelet Levels between Preeclampsia and Eclampsia Patients at Wiyung Sejahtera Hospital, Surabaya

Background: Indonesia is a developing country with a high maternal mortality rate (MMR) and perinatal mortality, the third highest in ASEAN and the second highest in the South East Asian Nation Regional Organization. In pregnancy hypertension has been proven that oxidants, especially if increased fat peroxide will damage endothelial cells called endothelial dysfunction. Vasospasm that occurs also induces platelet integration and endothelial damage which adds to the contribution in maintaining platelet dysfunction and triggering the use of platelets. Thrombocytopenia is the most important sign of the severity of preeclampsia.Objective: to determine the comparison of platelet levels in patients with preeclampsia with eclampsia.Methode: This study was observational cross sectional method. The sample in this study was a total sampling, using purposive sampling of patients with preeclampsia and eclampsia at the Wiyung Sejahtera Hospital in January-December 2019. The instrument used was using secondary data of medical records of patients.Results: Patients with preeclampsia have a minimum platelet level of 301,000/mm3, a maximum of 415,000/mm3, and an average of 351,733.33/mm3 with a standard deviation of 33,552.66/mm3. Patients with eclampsia have a minimum platelet level of 122,000/mm3, a maximum of 281,000/mm3, and an average of 209,200/mm3 with a standard deviation of 42,465.45/mm3. There are significant differences in platelet levels of patients with preeclampsia with eclampsia(p <0.05)..Conclusion: there is a significant difference between the platelet levels of patients with preeclampsia and eclampsia.

D-Dimer As a Predictor of Thrombotic Events during Early Acute Lymphoblastic Leukemia Therapy

Background Patients with acute lymphoblastic leukemia (ALL) are at increased risk of thrombotic and or bleeding events during chemotherapy, especially when receiving L-Asparaginase (ASP). Previous studies have identified variables associated with increased thrombotic risk in ALL including age, body mass index (BMI), sex, platelet count, and ASP use (Orvain 2020); however, to date no ALL-based study has examined D-dimer, a marker of fibrinolysis that has been shown to predict thrombosis in acute myelogenous leukemia (AML) (Libourel 2016), in this context. We sought to examine the utility of D-dimer as a biomarker for risk of thrombosis or bleeding events during ALL treatment. Methods In this retrospective cohort study we identified 61 adult patients with newly diagnosed ALL from a single center between 2008 and 2020. Patient demographic details, treatment regimens, and biomarkers including D-dimer (ordered routinely at diagnosis as a serum assay in mcg/ml FEU) were ascertained. Patients were stratified according to D-dimer level using a cut-off of ≥4 mcg/ml (high) and &lt;4 mcg/ml (low-moderate) based upon previous work examining D-dimer and thrombosis in AML (Libourel 2016). The disseminated intravascular coagulation (DIC) score according to the International Society on Thrombosis and Haemostasis (ISTH) was calculated at diagnosis. Major and clinically relevant non-major bleeding and first arterial or venous thrombotic event (confirmed by imaging) within 100 days of ALL diagnosis were recorded. The 100-day cumulative incidence of thrombosis was calculated for both D-dimer groups. Event rate was compared between D-dimer groups using chi-square analysis. Logistic regression was used to examine D-dimer as a continuous or categorical variable and compare events through 100 days. Six multivariate models, each including D-dimer and one of six previously identified thrombosis risk factors were performed. A receiver operating characteristic curve (ROC) was generated and area under the curve (AUC) calculated. Results Sixty-one patients with ALL were included; 52% were female and 48% male. Median age was 36 years (range 18-84). Patients were 18% Black, 26% Latinx, 52% White, and 3.3% Asian/Mideast Indian. Immunophenotypes included B-cell (82%), T-cell (8.2%), and mixed phenotype ALL (9.8%), with 24% of patients having Ph + or Ph-like status. ASP-based regimens were utilized in 67% of patients. The median D-dimer level was 2.1 mcg/ml (range: 0.26 to 20). The 100-day cumulative incidence of thrombosis was 53% (95% CI 26.4-73.8) in the high D-dimer group (N=17, 28%) and 14% (95% CI 5.5 - 25.5) in the low-moderate D-dimer group (N=44, 72%) (Figure 1). The rate of thrombosis was higher in the high D-dimer group, X2 (1, N=61) =10.2, p=.001. The odds of thrombosis within 100 days increased by 1.65 per every 3-unit increase in D-dimer (95% CI 1.2-2.27). The association between D-dimer and thrombosis remained after including additional confounders such as BMI, age, sex, ASP status, DIC score, and initial platelet level in covariate logistic regression models. ROC analysis demonstrated 60% sensitivity and 80% specificity for a D-dimer cutoff of 4 mcg/ml, with an AUC of 0.798 (95% CI 0.67-0.92). Clinically relevant bleeding occurred in 8 patients (13%) during the first 100 days after diagnosis and was not significantly associated with initial D-dimer level, BMI, age, sex, ASP status, DIC score, or initial platelet level. Conclusion High D-dimer (≥4 mcg/ml) at ALL diagnosis is associated with an increased rate of venous or arterial thrombosis within the first 100 days, with no increased rate of clinically relevant bleeding. D-dimer as a continuous variable appears to have good independent diagnostic discrimination for thrombosis. Prospective studies aiming to create ALL-specific thrombosis risk assessment models are warranted and should consider D-dimer level at diagnosis together with previously identified risk factors (Al-Ani 2020, Orvain 2020). Disclosures Leader: Bayer Healthcare: Other: personal fees ; Pfizer Pharmaceuticals Israel Ltd.: Consultancy, Honoraria, Other: personal fees .

Discharging dengue fever patients with low platelets can be safe

This is an interesting case of Mr MS who presented with 7 days of fever, loss of appetite and lethargy. Physical examination was unremarkable. Investigation revealed a very low platelet of 11 x 109/L and haematocrit of 46%. He was managed as outpatient and recovered well despite this alarming low platelet level, proving not all dengue fever patients ,especially those with no warning signs and clinically well, needs hospital admission. Bangladesh Journal of Medical Science Vol.19(4) 2020 p.760-762

Case of significantly delayed divalproex-induced thrombocytopaenia

We describe a 48-year-old male patient on long-term divalproex treatment for bipolar disorder who developed grade II thrombocytopaenia after approximately 18 years of therapy. Abrupt cessation of divalproex led to immediate platelet level reconstitution.

Risk factors for linezolid-associated thrombocytopenia and negative effect of carbapenem combination

Introduction: Linezolid is a synthetic antimicrobial agent with a broad spectrum of activity against virtually all Gram-positive bacteria. Although linezolid is generally well tolerated, the prolonged use of linezolid can lead to myelosuppression, including neutropenia, thrombocytopenia, and anemia. The aim of this study was investigating the risk factors for thrombocytopenia in patients who received linezolid therapy. Methodology: This retrospective study was performed on patients who received linezolid therapy between July 2007 and December 2017. Thrombocytopenia was defined as either a platelets count of < 100×109/L or a 25% reduction from the baseline platelet count. Results: A total of 371 patients, (198 (53%) male and 173(47%) female were included into the study. Mean duration of therapy was 12.81 ± 5.19 days. Linezolid-induced thrombocytopenia was detected in a total of 111 patients. Using the univariate analysis advanced sex, serum urea concentration, baseline platelet level and low eGFR value were found to be risk factors for linezolid associated thrombocytopenia (p < 0.05). According to a multivariate analysis, patients undergoing carbapenem treatment combination therapy (p = 0.003) and with a baseline platelet level of < 200×109/L (p = 0.00) were found to have a high risk of developing thrombocytopenia. Conclusions: Several factors may influence of linezolid associated thrombocytopenia. Platelet count should be monitored during therapy and thrombocytopenia should be kept in mind in patients with baseline platelet level of < 200×109/L, low eGFR, linezolid-carbapenem combination therapy.