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Bahr TM, Ohls RK, Ilstrup SJ, Christensen RD. Neonatal Intensive Care Unit Patients Receiving More Than 25 Platelet Transfusions. Am J Perinatol 2024; 41:e1769-e1774. [PMID: 37054977 DOI: 10.1055/a-2073-3848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
OBJECTIVE A few patients in neonatal intensive care units (NICU) receive numerous platelet transfusions. These patients can become refractory, defined as transfusions of ≥10 mL/kg failing to increase the platelet count by at least 5,000/µL. Causes of, and best treatments for, platelet transfusion refractoriness in neonates have not been defined. STUDY DESIGN Multi-NICU multiyear retrospective analysis of neonates receiving >25 platelet transfusions. RESULTS Eight neonates received 29 to 52 platelet transfusions. All eight were blood group O. Five had sepsis, four were very small for gestational age, four had bowel resections, two Noonan syndrome, two had cytomegalovirus infection. All eight had some (19-73%) refractory transfusions. Many (2-69%) of the transfusions were ordered when the platelet count was >50,000/µL. Higher posttransfusion counts occurred after ABO-identical transfusions (p = 0.026). Three of the eight had late NICU deaths related to respiratory failure; all five survivors had severe bronchopulmonary dysplasia requiring tracheostomy for prolonged ventilator management. CONCLUSION Neonates who are high users of platelet transfusions appear to be at high risk for poor outcomes, especially respiratory failure. Future studies will examine whether group O neonates are more likely to develop refractoriness and whether certain neonates would have a higher magnitude of posttransfusion rise if they received ABO-identical donor platelets. KEY POINTS · Many of the platelet transfusions given in the NICU are given to a small subset of patients.. · Refractoriness to platelet transfusions is common among these very high recipients.. · Neonates who are high users of platelet transfusions appear to be at high risk for poor outcomes..
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Affiliation(s)
- Timothy M Bahr
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, Utah
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
| | - Robin K Ohls
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, Utah
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
| | - Sarah J Ilstrup
- Intermountain Healthcare Transfusion Services and Department of Pathology, Intermountain Medical Center, Murray, Utah
| | - Robert D Christensen
- Obstetric and Neonatal Operations, Intermountain Healthcare, Murray, Utah
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
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2
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Li XX, Wang GR, Li C, He N, Yao P, Cheng YC, Wang CH, Ge QG, Yi M, Wang ZY, Shi LW, Zhao RS. Severe Thrombocytopenia Caused by Vancomycin in the Intensive Care Unit: A Case Report. Front Med (Lausanne) 2022; 9:829267. [PMID: 35755077 PMCID: PMC9218361 DOI: 10.3389/fmed.2022.829267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 04/12/2022] [Indexed: 12/20/2022] Open
Abstract
Thrombocytopenia can cause substantial morbidity and mortality in critically ill patients. There are multiple etiology factors and various mechanisms associated with thrombocytopenia, of which drug-induced thrombocytopenia (DITP) deserves attention. Herein, we describe a case of severe thrombocytopenia during intensive care unit (ICU) hospitalization that was likely to be associated with vancomycin. By revealing the process of identifying this case of DITP and reviewing relevant clinical studies, a risk alert of vancomycin-related severe hematotoxicity should be considered.
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Affiliation(s)
- Xiao-Xiao Li
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Guan-Ru Wang
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Chao Li
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Na He
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Peng Yao
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yin-Chu Cheng
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Chu-Hui Wang
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Qing-Gang Ge
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Min Yi
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Zong-Yu Wang
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Lu-Wen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Rong-Sheng Zhao
- Department of Pharmacy and Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
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3
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Nie X, Jia L, Peng X, Zhao H, Yu Y, Chen Z, Zhang L, Cheng X, Lyu Y, Cao W, Wang X, Ni X, Zhan S. Detection of Drug-Induced Thrombocytopenia Signals in Children Using Routine Electronic Medical Records. Front Pharmacol 2021; 12:756207. [PMID: 34867372 PMCID: PMC8633439 DOI: 10.3389/fphar.2021.756207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/20/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Drug-induced thrombocytopenia (DITP) is a severe adverse reaction and a significantly under-recognized clinical problem in children. However, for post-marketing pharmacovigilance purposes, detection of DITP signals is crucial. This study aimed to develop a signal detection model for DITP using the pediatric electronic medical records (EMR) data. Methods: This study used the electronic medical records collected at Beijing Children’s Hospital between 2009 and 2020. A two-stage modeling method was developed to detect the signal of DITP. In the first stage, we calculated the crude incidence by mining cases of thrombocytopenia to select the potential suspected drugs. In the second stage, we constructed propensity score–matched retrospective cohorts of specific screened drugs from the first stage and estimated the odds ratio (OR) and 95% confidence interval (CI) using conditional logistic regression models. The novelty of the signal was assessed by current evidence. Results: In the study, from a total of 839 drugs, 21 drugs were initially screened as potentially inducing thrombocytopenia. In total, we identified 18 positive DITP associations. Of these, potential DITP risk of nystatin (OR: 1.75, 95% CI: 1.37–2.22) and latamoxef sodium (OR: 1.61, 95% CI: 1.38–1.88) were two new DITP signals in both children and adults. Six associations between thrombocytopenia and drugs including imipenem (OR: 1.69, 95% CI: 1.16–2.45), teicoplanin (OR: 4.75, 95% CI: 3.33–6.78), fusidic acid (OR: 2.81, 95% CI: 2.06–3.86), ceftizoxime sodium (OR: 1.83, 95% CI: 1.36–2.45), ceftazidime (OR: 2.16, 95% CI: 1.58–2.95), and cefepime (OR: 5.06, 95% CI: 3.77–6.78) were considered as new signals in children. Conclusion: This study developed a two-stage algorithm to detect safety signals of DITP and found eighteen positive signals of DITP, including six new signals in a pediatric population. This method is a promising tool for pharmacovigilance based on EMR data.
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Affiliation(s)
- Xiaolu Nie
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.,Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lulu Jia
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoxia Peng
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Houyu Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yuncui Yu
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Liqiang Zhang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yaqi Lyu
- Department of Medical Record Management, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wang Cao
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xin Ni
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.,Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
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4
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Abstract
Entecavir (ETV) is widely used in the treatment of hepatitis B, but there are only a few reports about entecavir-associated thrombocytopenia, and it is considered as an immediate response and inappropriate to continue the treatment with other nucleoside analogues. Now, we report the third case, and this case was delayed response and we switched to treatment with tenofovir (TDF). There was a 66-year-old female who was infected with hepatitis B virus (HBV). Her platelet count decreased from 111*109/L to 3*109/L and was prone to gum bleeding and skin ecchymosis after she received ETV treatment for 88 days. As a treatment option, ETV was replaced by TDF immediately, frequent platelets transfusions and thrombopoietin were applied for several days, daily prednisone of 50 mg was concomitantly taken, and then platelet count improved after 10 days. She was diagnosed with entecavir-associated thrombocytopenia after analysis of the temporal relationship and exclusion of other causes of thrombocytopenia by blood and bone marrow examinations. Our case suggested that the platelet count should be monitored regularly in patients during ETV treatment, and it may be a feasible option to choose TDF to maintain antiviral treatment when entecavir-associated thrombocytopenia occurs.
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Affiliation(s)
- Yi Yu
- Infectious Diseases Section, 91599Nanjing Jiangbei Hospital, Nanjing, China
| | - Hao Feng
- Infectious Diseases Section, 91599Nanjing Jiangbei Hospital, Nanjing, China.,Infectious Diseases Section, 12461Nanjing Pukou Central Hospital, Jiangsu Provincial People's Hospital Pukou Branch, Nanjing, China
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5
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Elrashdy F, Tambuwala MM, Hassan SS, Adadi P, Seyran M, Abd El-Aziz TM, Rezaei N, Lal A, Aljabali AAA, Kandimalla R, Bazan NG, Azad GK, Sherchan SP, Choudhury PP, Serrano-Aroca Á, Takayama K, Chauhan G, Pizzol D, Barh D, Panda PK, Mishra YK, Palù G, Lundstrom K, Redwan EM, Uversky VN. Autoimmunity roots of the thrombotic events after COVID-19 vaccination. Autoimmun Rev 2021; 20:102941. [PMID: 34508917 PMCID: PMC8426137 DOI: 10.1016/j.autrev.2021.102941] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 06/06/2021] [Indexed: 02/03/2023]
Abstract
Although vaccination represents the most promising way to stop or contain the coronavirus disease 2019 (COVID-19) pandemic and safety and effectiveness of available vaccines were proven, a small number of individuals who received anti-SARS-CoV-2 vaccines developed a prothrombotic syndrome. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can be triggered by the adenoviral vector-based vaccine, whereas lipid nanoparticle-mRNA-based vaccines can induce rare cases of deep vein thrombosis (DVT). Although the main pathogenic mechanisms behind this rare phenomenon have not yet been identified, both host and vaccine factors might be involved, with pathology at least in part being related to the vaccine-triggered autoimmune reaction. In this review, we are considering some aspects related to pathogenesis, major risk factors, as well as peculiarities of diagnosis and treatment of this rare condition.
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Affiliation(s)
- Fatma Elrashdy
- Department of Endemic Medicine and Hepatogastroenterology, Kasr Alainy, Cairo University, Cairo, Egypt.
| | - Murtaza M Tambuwala
- School of Pharmacy and Pharmaceutical Sciences, Ulster University, Coleraine, BT52 1SA, Northern Ireland, United Kingdom.
| | - Sk Sarif Hassan
- Department of Mathematics, Pingla Thana Mahavidyalaya, Maligram, 722140 Paschim Medinipur, West Bengal, India
| | - Parise Adadi
- Department of Food Science, University of Otago, Dunedin, New Zealand
| | - Murat Seyran
- Doctoral Student in Natural and Technical Sciences (SPL 44), University of Vienna, Währinger Straße, A-1090 Vienna, Austria.
| | - Tarek Mohamed Abd El-Aziz
- Zoology Department, Faculty of Science, Minia University, El-Minia 61519, Egypt; Department of Cellular and Integrative Physiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Stockholm, Sweden
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
| | - Alaa A A Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Yarmouk University, Irbid 21163, P. O. BOX 566, Jordan.
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Chemical Technology, Uppal Road, Tarnaka, Hyderabad 500007, India; Department of Biochemistry, Kakatiya Medical College, Warangal, India
| | - Nicolas G Bazan
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, Louisiana, 70112, USA.
| | | | - Samendra P Sherchan
- Department of Environmental Health Sciences, Tulane University, New Orleans, LA 70112, USA.
| | - Pabitra Pal Choudhury
- Applied Statistics Unit, Indian Statistical Institute, Kolkata, 700108, West Bengal, India
| | - Ángel Serrano-Aroca
- Biomaterials and Bioengineering Lab, Centro de Investigación Traslacional San Alberto Magno, Universidad Católica de Valencia San Vicente Mártir, c/Guillem de Castro 94, Valencia 46001, Spain.
| | - Kazuo Takayama
- Center for iPS Cell Research and Application (CiRA), Kyoto University, Kyoto 606-8507, Japan.
| | - Gaurav Chauhan
- School of Engineering and Sciences, Tecnológico de Monterrey, Av. Eugenio Garza Sada 2501 Sur, 64849 Monterrey, Nuevo León, Mexico.
| | - Damiano Pizzol
- Italian Agency for Development Cooperation -, Khartoum, Sudan Street 33, Al Amarat, Sudan
| | - Debmalya Barh
- Institute of Integrative Omics and Applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, WB-721172, India; and Departamento de Genética, Ecologia e Evolução, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil.
| | - Pritam Kumar Panda
- Condensed Matter Theory Group, Materials Theory Division, Department of Physics and Astronomy, Uppsala University, Box 516, SE-751 20 Uppsala, Sweden.
| | - Yogendra K Mishra
- University of Southern Denmark, Mads Clausen Institute, NanoSYD, Alsion 2, 6400 Sønderborg, Denmark.
| | - Giorgio Palù
- Department of Molecular Medicine, University of Padova, Italy.
| | | | - Elrashdy M Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Vladimir N Uversky
- Department of Molecular Medicine, University of South Florida, Tampa, FL, United States.
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6
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Schoonjans A, Maes P, Ceulemans B. Aggravation of valproic acid induced thrombocytopenia after the introduction of fenfluramine, a case report. Seizure 2021; 93:60-62. [PMID: 34706322 DOI: 10.1016/j.seizure.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/16/2022] Open
Affiliation(s)
- A Schoonjans
- Department of Pediatric neurology, University Hospital of Antwerp, Antwerp University, Drie Eikenstraat 655, Edegem 2650, Belgium.
| | - P Maes
- Department of Pediatrics, University Hospital of Antwerp, Antwerp University, Edegem, Belgium
| | - B Ceulemans
- Department of Pediatric neurology, University Hospital of Antwerp, Antwerp University, Drie Eikenstraat 655, Edegem 2650, Belgium
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7
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Lewen MO, Berry J, Johnson C, Grace R, Glader L, Crofton C, Leahy I, Pallikonda N, Litvinova A, Staffa SJ, Glotzbecker M, Emans J, Hresko MT, Ellen M, Troy M, Singer SJ, Ferrari L. Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis. J Perioper Pract 2021; 32:74-82. [PMID: 33826437 DOI: 10.1177/1750458920962634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis. METHODS Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes. RESULTS In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 109/L. CONCLUSIONS Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.
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Affiliation(s)
- Margaret O Lewen
- Department of Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Jay Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Connor Johnson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachael Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Laurie Glader
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charis Crofton
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Izabela Leahy
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikhil Pallikonda
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Litvinova
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Glotzbecker
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Ellen
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Troy
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara J Singer
- Department of Organizational Behavior and Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lynne Ferrari
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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8
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Resch B. Thrombocytopenia in Neonates. Platelets 2020. [DOI: 10.5772/intechopen.92857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thrombocytopenia defined as platelet count below 150,000/μL is not an uncommon event at the neonatal intensive care unit (NICU). In our region we calculated a prevalence of nearly 2 of 1000 live births. Early-onset neonatal thrombocytopenia (NT) occurring within the first 72 hours of life is more common than late-onset NT. Preterm infants are affected more often than term infants and bacterial infection is the most common diagnosis associated with NT. There are a lot of maternal, perinatal, and neonatal causes associated with NT and complications include bleedings with potentially life-threatening intracranial hemorrhage. Alloimmune thrombocytopenia (NAIT) often presents with severe thrombocytopenia (<30,000/μL) in otherwise healthy newborns and needs careful evaluation regarding HPA-1a antigen status and HLA typing. Platelet transfusions are needed in severe NT and threshold platelet counts might be at ≤25,000/μL irrespective of bleeding or not. Immune mediated NT recovers within 2 weeks with a good prognosis when there happened no intracranial hemorrhage. This short review gives an overview on etiology and causes of NT and recommendations regarding platelet transfusions.
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9
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Abstract
After vascular injury and exposure of subendothelial matrix proteins to the intravascular space, mediators of hemostasis are triggered and allow for clot formation and restoration of vascular integrity. Platelets are the mediators of primary hemostasis, creating a platelet plug and allowing for initial cessation of bleeding. Platelet disorders, qualitative and quantitative, may result in bleeding signs and symptoms, particularly mucocutaneous bleeding such as epistaxis, bruising, petechiae, and heavy menstrual bleeding. Increasing evidence suggests that platelets have functional capabilities beyond hemostasis, but this review focuses solely on platelet hemostatic properties. Herein, normal platelet function as well as the effects of abnormal function and thrombocytopenia are reviewed.
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Affiliation(s)
- Kristina M Haley
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
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10
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Hoste L, George I. Ranitidine-induced Thrombocytopenia in a Neonate - A Case Report and Review of Literature. J Pediatr Pharmacol Ther 2019; 24:66-71. [PMID: 30837818 DOI: 10.5863/1551-6776-24.1.66] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Thrombocytopenia (platelet count <150 × 109/L) regularly occurs in newborns but is especially observed in critically ill neonates. We describe the case of a small for gestational age (SGA) neonate, who showed an unexpected, severe thrombocytopenia (8 × 109/L) at day 5 of life. The thrombocytopenia recovered completely after cessation of ranitidine (0.5 mg/kg/6 hr), which was started in a context of feeding difficulties. Other causes of neonatal thrombocytopenia were ruled out. Besides a brief report on a cimetidine-induced thrombocytopenia over 25 years ago, no other neonatal or pediatric cases of H2 antagonist-induced thrombocytopenia have been reported to date, although being widely used in routine care. Moreover, several adult cases have been published. In general, neonatal thrombocytopenia, although one of the most frequent hematological conditions in newborns, is only rarely attributed to an adverse drug reaction. Clinicians should be aware of the risks for adverse reactions, especially in routinely used drugs and in critically ill patients.
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11
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12
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Herrera A, Vajravelu ME, Givler S, Mitteer L, Avitabile CM, Lord K, De León DD. Prevalence of Adverse Events in Children With Congenital Hyperinsulinism Treated With Diazoxide. J Clin Endocrinol Metab 2018; 103:4365-4372. [PMID: 30247666 PMCID: PMC6207144 DOI: 10.1210/jc.2018-01613] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/04/2018] [Indexed: 12/30/2022]
Abstract
CONTEXT Diazoxide, the only U.S. Food and Drug Administration-approved drug to treat hyperinsulinemic hypoglycemia, has been associated with several adverse events, which has raised concerns about the safety of this drug. Existing reports are limited to small studies and case reports. OBJECTIVE To determine prevalence of and clinical factors associated with adverse events in infants and children treated with diazoxide. DESIGN Retrospective cohort study of children with hyperinsulinism (HI) treated with diazoxide between 2003 and 2014. SETTING The Congenital Hyperinsulinism Center at the Children's Hospital of Philadelphia. PATIENTS Children and infants with laboratory-confirmed diagnosis of HI. MAIN OUTCOME MEASURES Prevalence of pulmonary hypertension (PH), edema, neutropenia, thrombocytopenia, and hyperuricemia was determined. Tests of association and logistic regression were used to identify potential risk factors. RESULTS A total of 295 patients (129 female) met inclusion criteria. The median age at diazoxide initiation was 29 days (interquartile range, 10 to 142 days; n = 226 available start dates); 2.4% of patients were diagnosed with PH after diazoxide initiation. Children with PH (P = 0.003) or edema (P = 0.002) were born at earlier gestational age and more frequently had potential PH risk factors, including respiratory failure and structural heart disease (P < 0.0001 and P = 0.005). Other adverse events included neutropenia (15.6%), thrombocytopenia (4.7%), and hyperuricemia (5.0%). CONCLUSION In this large cohort, PH occurred in infants with underlying risk factors, but no identifiable risk profile emerged for other adverse events. The relatively high prevalence of neutropenia, thrombocytopenia, and hyperuricemia suggests the value in proactively screening for these side effects in children treated with diazoxide.
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Affiliation(s)
- Adriana Herrera
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mary Ellen Vajravelu
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephanie Givler
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lauren Mitteer
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine M Avitabile
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katherine Lord
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Diva D De León
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Correspondence and Reprint Requests: Diva D. De León, MD, Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Suite 11NW30, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104. E-mail:
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13
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Kim JY. Diagnostic Approach of Childhood Immune Thrombocytopenia. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2018. [DOI: 10.15264/cpho.2018.25.1.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ji Yoon Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
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Bleeding frequency and characteristics among hematologic malignancy inpatient rehabilitation patients with severe thrombocytopenia. Support Care Cancer 2018; 26:3135-3141. [PMID: 29594490 DOI: 10.1007/s00520-018-4160-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/12/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To identify the frequency and characteristics of bleeding complications during acute inpatient rehabilitation of hematologic malignancy patients with severe thrombocytopenia. DESIGN Retrospective descriptive analysis. SETTING Comprehensive cancer center acute inpatient rehabilitation unit. PARTICIPANTS Consecutive hematologic malignancy patients with a platelet count of less than or equal to 20,000/microliter (μL) on the day of acute inpatient rehabilitation admission from 1/1/2005 through 8/31/2016. INTERVENTIONS Medical records were retrospectively analyzed for demographic, laboratory, and medical data. Patients were rehabilitated using the institutional exercise guidelines for thrombocytopenic patients. MAIN OUTCOME MEASURES Bleeding events noted in the medical record. RESULTS Out of 135 acute inpatient rehabilitation admissions, 133 unique patients were analyzed with a total of 851 inpatient rehabilitation days. The mean platelet count was 14,000/μL on the day of admission and 22,000/μL over the course of the rehabilitation admission. There were 252 days of inpatient rehabilitation where patients had less than 10,000/μL platelets. A total of 97 bleeding events were documented in 77/135 (57%) admissions. Of the 97 bleeding events, 72 (74%), 14 (14%), and 11 (11%) were considered to be of low, medium, and high severity, respectively. There were 4/97 (4%) bleeding events that were highly likely attributable to physical activity but only 1/4 was considered high severity. Bleeding rates were .09, .08, .17, and .37 for > 20,000, 15-20,000, 10-15,000, and < 10,000/μL mean platelet counts respectively (p = .003). Forty-four percent of patients were transferred back to the primary acute care service with infection being the most common reason for transfer. CONCLUSIONS This study is the first to examine exercise-related bleeding complications during acute inpatient rehabilitation in severely thrombocytopenic hematologic cancer patients. Bleeding rates increased with lower platelet counts. However, using the exercise guidelines for severely thrombocytopenic patients, the risk of severe exercise-related bleeding events was low.
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15
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Elzagallaai AA, Greff M, Rieder MJ. Adverse Drug Reactions in Children: The Double-Edged Sword of Therapeutics. Clin Pharmacol Ther 2017; 101:725-735. [PMID: 28295234 DOI: 10.1002/cpt.677] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/06/2017] [Accepted: 03/08/2017] [Indexed: 12/14/2022]
Abstract
Adverse drug reactions (ADRs) represent a major health problem worldwide, with high morbidity and mortality rates. ADRs are classified into Type A (augmented) and Type B (bizarre) ADRs, with the former group being more common and the latter less common but often severe and clinically more problematic due to their unpredictable nature and occurrence at any dose. Pediatric populations are especially vulnerable to ADRs due to the lack of data for this age group from the drug development process and because of the wide use of off-label and unlicensed use of drugs. Children are more prone to specific types of ADRs because of the level of maturity of body systems involved in absorption, metabolism, transportation, and elimination of drugs. This state-of-the-art review provides an overview of definitions, classifications, epidemiology, and pathophysiology of ADRs and discusses the available evidence for related risk factors and causes of ADRs in the pediatric population.
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Affiliation(s)
- A A Elzagallaai
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.,Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada.,Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Mje Greff
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.,Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - M J Rieder
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.,Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada.,Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Division of Clinical Pharmacology, Department of Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
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16
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Consolini R, Costagliola G, Spatafora D. The Centenary of Immune Thrombocytopenia-Part 2: Revising Diagnostic and Therapeutic Approach. Front Pediatr 2017; 5:179. [PMID: 28871277 PMCID: PMC5566994 DOI: 10.3389/fped.2017.00179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/07/2017] [Indexed: 01/19/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children and adolescents and can be considered as a paradigmatic model of autoimmune disease. This second part of our review describes the clinical presentation of ITP, the diagnostic approach and overviews the current therapeutic strategies. Interestingly, it suggests an algorithm useful for differential diagnosis, a crucial process to exclude secondary forms of immune thrombocytopenia (IT) and non-immune thrombocytopenia (non-IT), which require a different therapeutic management. Advances in understanding the pathogenesis led to new therapeutic targets, as thrombopoietin receptor agonists, whose role in treatment of ITP will be discussed in this work.
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Affiliation(s)
- Rita Consolini
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Giorgio Costagliola
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Davide Spatafora
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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17
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Hayashi M, Strouse JJ, Veltri MA, Curtis BR, Takemoto CM. Immune thrombocytopenia due to Trimethoprim-Sulfamethoxazole; under-recognized adverse drug reaction in children? Pediatr Blood Cancer 2015; 62:922-3. [PMID: 25683320 PMCID: PMC4559584 DOI: 10.1002/pbc.25430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/22/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Masanori Hayashi
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John J. Strouse
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A. Veltri
- Department of Pharmacy, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brian R. Curtis
- Platelet and Neutrophil Immunology Lab BloodCenter of Wisconsin, Milwaukee, WI
| | - Clifford M. Takemoto
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Trifa M, Ben Yahia MM, Saada S, Akrout S, Ghlala A, Fakhfakh R, Fekih Hassen A, Ben Khalifa S. [Thrombopenia and the nature of the microorganism in infected critically ill children]. Arch Pediatr 2014; 21:1073-8. [PMID: 25125030 DOI: 10.1016/j.arcped.2014.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 11/28/2013] [Accepted: 06/23/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Thrombopenia is correlated with sepsis and mortality in pediatric intensive care units. The purpose of this study was to find an association between thrombopenia and the microorganism type to guide the choice of empiric antibiotic therapy in infected critically ill children. MATERIALS AND METHODS We conducted a prospective descriptive study, including all newborns, infants, and children admitted to a pediatric surgical intensive care unit from 1st January to 31st December 2009. We identified patients who developed an infection and/or thrombopenia (platelet count less than 100,000/mm(3)) during hospitalization. RESULTS One hundred ninety-seven patients were included (57 newborns, 41 infants, 99 children). Ninety patients developed 100 infectious episodes during the study period. Of the 57 newborns enrolled in the study, 31 (54%) developed 37 infections. Seventy-six microorganisms (55 Gram-negative bacilli [GNB], 17 Gram-positive cocci, two Gram-negative cocci, two fungal pathogens) were identified during 65 infectious episodes in 55 patients. Thirty-four episodes of thrombopenia were observed in 30 patients. Thrombopenia was observed only in infected patients (P<0.001). Thrombopenia was associated with infections caused by GNB (26/28 vs 20/37, P=0.001) and by Klebsiella (16/28 vs 6/37, P=0.001) and may be associated with infections caused by GNB producing extended-spectrum beta-lactamases (P=0.07). Gram-positive cocci infections were correlated to the non-occurrence of thrombopenia (P=0.02). Postoperative peritonitis was also significantly associated with thrombopenia (P=0.03). The mortality rate in our patients was 12.7% (22.8% in neonates). There was an association between thrombopenia and death in univariate analysis (11/25 vs 19/172, P<0.001). Multivariate logistic regression analysis did not confirm thrombopenia as an independent predictive factor of mortality in children. CONCLUSION Because of the relatively high proportion of resistant GNB, an empiric antibiotic therapy combining a carbapenem and an aminoglycoside may be indicated in infected critically ill children developing thrombopenia.
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Affiliation(s)
- M Trifa
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie.
| | - M M Ben Yahia
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie
| | - S Saada
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie
| | - S Akrout
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie
| | - A Ghlala
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie
| | - R Fakhfakh
- Service d'épidémiologie et de médecine préventive, faculté de médecine, université Tunis El Manar, Tunis, Tunisie
| | - A Fekih Hassen
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie
| | - S Ben Khalifa
- Service d'anesthésie réanimation, faculté de médecine, université Tunis El Manar, hôpital d'enfants, Bab Saadoun, 1006 Tunis, Tunisie
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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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