Entecavir-Associated Thrombocytopenia in a Decompensated Cirrhotic Patient: A Case Report and Literature Review

Thrombocytopenia as an important determinant of poor prognosis in patients with pyogenic liver abscess: a retrospective case series

BACKGROUND

Thrombocytopenia and poor prognosis in severe conditions are associated. However, the clinical significance of thrombocytopenia in pyogenic liver abscess (PLA) has not been evaluated.

OBJECTIVE

To evaluate the association between thrombocytopenia and the prognosis of patients with PLA.

METHODS

A consecutive case series of 458 adult patients with PLA hospitalized at Tongji Hospital (Wuhan, China) between October 2011 and June 2021 was included in this cross-sectional analysis. Patient data were compared between the thrombocytopenia and non-thrombocytopenia groups. Multivariate logistic regression, receiver operating characteristic (ROC) curve and propensity score -matched analyses (PSM) were performed.

RESULTS

Of the 458 patients with PLA, 94 (20.5%) developed thrombocytopenia, 19 (4.1%) developed septic shock, 14 (3.1%) were admitted to the ICU, and 15 (3.3%) died during hospitalization. Thrombocytopenia was independently associated with shock (95%CI = 3.529-57.944, P < 0.001), ICU admission (95%CI = 1.286-25.733, P = 0.022), and mortality (95%CI = 1.947-34.223, P = 0.004) in multivariate regression analysis. ROC analysis showed that thrombocytopenia may be an identified marker of shock [area under the ROC curve (AUC), 0.8119; cut-off, 92.50; P < 0.0001], ICU admission (AUC, 0.7484; cut-off, 82.50; P < 0.0015), and mortality (AUC, 0.7827; cut-off, 122.50; P < 0.002). These findings remained consistent across 86 pairs of patients analyzed for PSM analyses.

CONCLUSIONS

Thrombocytopenia is an independent risk factor for poor prognosis in PLA and patients may be more prone to adverse outcomes.

Entecavir-associated thrombocytopenia

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.

Association between thrombocytopenia and 180-day prognosis of COVID-19 patients in intensive care units: A two-center observational study

BACKGROUND

Thrombocytopenia has been proved to be associated with hospital mortality in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. However, the detailed association of thrombocytopenia with subsequent progression of organ functions and long-term prognosis in critically ill COVID-19 patients remains to be explored.

METHODS

Medical records of 167 confirmed cases of critically ill COVID-19 from February 16 to March 21, 2020 were collected in this two-center retrospective study. 180-day's outcome and clinical organ development in patients with thrombocytopenia and non-thrombocytopenia were analyzed.

FINDINGS

Among all 167 patients, the median age was 66 years and 67.07% were male. Significant differences were noticed in laboratory findings including white blood cells, blood urea, total bilirubin, lactate dehydrogenase and SOFA score between groups of thrombocytopenia and non-thrombocytopenia. Older age, lower platelet count and longer activated partial thromboplastin time at admission were determined to be risk factors of 28-day mortality, and all three, together with higher white blood cells were risk factors of 180-day mortality. Subsequent changes of six-point ordinal scale score, oxygenation index, and SOFA score in patients with thrombocytopenia showed marked worsening trends compared with patients without thrombocytopenia. Patients with thrombocytopenia had significantly higher mortality not only in 28 days, but also in 90 days and 180 days. The time-course curves in non-survival group showed a downtrend of platelet count and oxygenation index, while the curve of six-point ordinal scale kept an uptrend. Kaplan-Meier analysis indicated that patients with thrombocytopenia had much lower probability of survival (p<0.01).

INTERPRETATION

The thrombocytopenia was associated with the deterioration of respiratory function. Baseline platelet count was associated with subsequent and long-term mortality in critically ill COVID-19 patients.

Effects of hepatitis B virus infection and antiviral therapy on the clinical prognosis of nasopharyngeal carcinoma

Purpose

To investigate the clinical characteristics of nasopharyngeal carcinoma (NPC) and a concomitant hepatitis B virus (HBV) infection, as well as the potential effects of HBV infection and antiviral therapy on prognosis.

Methods

We conducted a retrospective chart review of all NPC patients from December 2010 to December 2014. After collecting medical records and conducting follow‐ups on patients, a total of 876 eligible NPC patients were included. For each patient, medical records were reviewed. Factors predictive of outcome were compared using the log‐rank test and Cox regression analysis.

Results

Among the 876 participants, 106 (12.1%) patients were HBV‐infected patients. The hepatitis B surface antigen‐positive [HBsAg(+)] group had a lower CD⁴⁺ T cell count than the HBsAg(−) group (P = .048). Among patients with stage I/II NPC, 5‐year overall survival (OS), disease‐free survival (DFS), relapse‐free survival, and distant metastasis‐free survival (DMFS) of the HBsAg(+) group were 82.5%, 70.7%, 87.7%, and 76.6%, respectively, whereas those of the HBsAg(−) group were 91.4%, 86.0%, 93.8%, and 92.1%, respectively. Statistically significant differences in OS, DFS, and DMFS existed between both groups (P = .017, .018, and .004, respectively). The multivariate analysis indicated that HBsAg status and N stage are independent risk factors affecting OS, DFS, and DMFS of NPC patients. A statistically significant difference in 5‐year DMFS existed between the antivirus (90.0%) and no‐antivirus groups (70.0%) (P = .043).

Conclusions

Hepatitis B virus infection is an independent risk factor for early stage NPC, which may be associated with its reduced immune functions compared to the HBsAg(−) group. Anti‐HBV treatment may improve the prognosis of HBV‐infected NPC patients.

Entecavir-Associated Thrombocytopenia: A Case Report and Review of the Pathophysiology, Diagnosis, and Treatment of a Rare but Reversible Cause of Thrombocytopenia

Drug-associated thrombocytopenia is often unrecognized. We report a 76-year-old female with lymphoma who presented with easy bruising and oral bleeding. She had undergone screening for hepatitis B virus (HBV) prior to starting rituximab and was found to have hepatitis B core serum antibody (IgG anti-HBc). She was therefore treated with prophylactic entecavir 0.5 mg daily to prevent reactivation of HBV. Her initial platelet count was 136,000/mm³. Five days after starting entecavir, she presented with bruising and oral bleeding and was found to have a platelet count of 7,000/mm³. A coagulation profile and the rest of the blood parameters (RBC and WBC counts) were normal. Entecavir was stopped, and she was given 3 units of apheresed platelets followed by intravenous immunoglobulin (1 g/kg) for 5 consecutive days. Her platelet counts improved and normalized in one week. She was diagnosed with entecavir-induced thrombocytopenia based on the temporal relationship and after carefully excluding alternate causes of thrombocytopenia. This case highlights the importance of recognizing drug-induced thrombocytopenia (DITP) as a reversible cause of thrombocytopenia.

Tenofovir induced severe thrombocytopenia

Tenofovir disoproxil fumarate is used in the management of hepatitis B and human immunodeficiency virus infection. We present a 50 years old lady, post liver transplant, who was switched over from entecavir to tenofovir, for management of hepatitis B reactivation. She developed bleeding diathesis and severe thrombocytopenia was detected on investigations. Bone marrow examination showed normocellular marrow with megakaryocytes. Tenofovir was stopped and she was started on intravenous immunoglobulin, followed by steroids. There was improvement in platlet counts. The case highlights a rare side effect of tenofovir therapy.