A 7-year case of furosemide-induced immune thrombocytopenia

Furosemide-induced haemolytic anaemia in an extreme elderly patient

Furosemide, a loop diuretic, is commonly used to treat fluid overload symptoms and heart failure. Drug-induced immune haemolytic anaemia is an unusual drug-adverse event. Furosemide-induced haemolysis is even rarer. This case report presents a 91-year-old male who developed acute haemolytic anaemia 3 days after initiating furosemide to treat myocardial infarction complicated with acute decompensated heart failure. He had increased lactate dehydrogenase and unconjugated bilirubin with undetectable haptoglobin, which indicated the destruction of red blood cells. Other causes for haemolytic anaemia, including hereditary, microangiopathic haemolytic anaemia, and paroxysmal nocturnal haemoglobinuria, were also excluded. He improved with drug cessation and a short course of glucocorticoids. This report aims to raise awareness of this rare complication caused by commonly prescribed drugs. Despite a negative result of a direct antiglobulin test, physicians must remain suspicious of drug-induced immune haemolytic anaemia in unclear cases of haemolysis.

Furosemide-Induced Thrombotic Thrombocytopenic Purpura: A Report of a Rare Case

Drug-induced immune thrombocytopenia (DITP) refers to drug-dependent, antibody-mediated platelet destruction. Although several drugs have been implicated as the cause of DITP, the most commonly encountered are heparin, sulfonamides, quinine, vancomycin, and beta-lactam antibiotics. However, furosemide has been rarely reported as the cause of thrombocytopenia. We present a unique case of furosemide-induced thrombotic thrombocytopenia in a 64-year-old female referred by her primary care provider for low platelets, rash, and bleeding. She was recently started on oral furosemide for diastolic heart failure two weeks before this presentation. She was admitted to the intensive care unit and was worked up for new-onset thrombocytopenia. Labs revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and low haptoglobin with normal serum creatinine. Peripheral smear showed schistocytes, low platelets, and ADAMTS13 level was 0.03. The patient was diagnosed with thrombotic thrombocytopenic purpura and treated with steroids, rituximab, and plasmapheresis, which led to rapid recovery of the platelet count to normal. Based on this case report, clinicians should consider furosemide as one of the drugs potentially causing thrombotic thrombocytopenia. Early detection and prompt management can be lifesaving.

Case Report: First Case of Cefotaxime-Sulbactam-Induced Acute Intravascular Hemolysis in a Newborn With ABO Blood Type Incompatibility by the Mechanism of Non-Immunologic Protein Adsorption

Background

ABO blood type incompatibility hemolytic disease of newborn (ABO-HDN) and drug-induced immune hemolytic anemia (DIIHA) due to non-immunologic protein adsorption (NIPA) mainly cause extravascular hemolysis. All the reported severe DIIHA were caused by drug-induced antibodies, and rare report of acute intravascular hemolysis was caused by the NIPA mechanism or ABO-HDN.

Case presentation

We report the first case of acute intravascular hemolysis induced by cefotaxime sodium - sulbactam sodium (CTX - SBT) in a case of ABO-HDN which resulted in death at 55 h after birth. The mother’s blood type was O and RhD-positive, and the newborn’s blood type was B and RhD-positive. No irregular red blood cell (RBC) antibodies or drug-dependent antibodies related to CTX or SBT was detected in the mother’s plasma and the plasma or the RBC acid eluent of the newborn. Before the newborn received CTX - SBT treatment, the result of direct antiglobulin test (DAT) was negative while anti-B was positive (2 +) in both plasma and acid eluent. After the newborn received CTX - SBT treatment, the results of DAT for anti-IgG and anti-C3d were both positive, while anti-B was not detected in plasma, but stronger anti-B (3 +) was detected in acid eluent. In vitro experiments confirmed that NIPA of SBT promoted the specific binding of maternal-derived IgG anti-B to B antigen on RBCs of the newborn, thereby inducing acute intravascular hemolysis.

Conclusion

The NIPA effect of SBT promoted the specific binding of mother-derived IgG anti-B in newborn’s plasma to the newborn’s RBC B antigens and formed an immune complex, and then activated complement, which led to acute intravascular hemolysis. Drugs such as SBT with NIPA effect should not be used for newborns with HDN.

Case report: apixaban-induced thrombocytopenia

Apixaban is a relatively new drug, and its safety profile is still being established. Thrombocytopenia is an uncommon, but life‐threatening side effect with no previous published case repots. Clinicians must be aware of this and exercise caution particularly as some studies hint that it may be used in the management of HIT.