Severe Agranulocytosis following Simultaneous Administration of Chlorpromazine and Trimethoprim-Sulfamethoxazole in a Patient with Sepsis: A Possible Toxic Combination

Agranulocytosis Associated With Use of Sulfamethoxazole/Trimethoprim in a Healthy Adult

Purpose: A case of sulfamethoxazole/trimethoprim-induced agranulocytosis is reported. Summary: A 53-year-old healthy male presented to the emergency room with a fever of 102.7°F and was found to have a white blood cell (WBC) count of 0.6 × 103 cells/μL with an absolute neutrophil count (ANC) of 0.0 x 103 cells/μL. He had recently completed a 10-day course of sulfamethoxazole/trimethoprim for left lower extremity cellulitis. During admission, a bone marrow biopsy was performed which was not concerning for malignancy and no cause for the agranulocytosis other than the sulfamethoxazole/trimethoprim was identified. The agranulocytosis resolved after 6 days of hospitalization with a WBC count of 8.9 × 103 cells/μL and an ANC of 4.1 x 103cells/μL on the day of discharge. Conclusion: A 53-year-old male developed agranulocytosis after 10 days of sulfamethoxazole/trimethoprim therapy for the treatment of a skin and soft tissue infection. His neutropenia resolved after sulfamethoxazole/trimethoprim discontinuation.

Outcomes of granulocyte colony-stimulating factor use in pediatric kidney transplant recipients: A Pediatric Nephrology Research Consortium study

BACKGROUND

Neutropenia is common in the first year after pediatric kidney transplant and is associated with an increased risk of infection, allograft loss, and death. Granulocyte colony-stimulating factor (G-CSF) increases neutrophil production, but its use in pediatric solid organ transplant recipients remains largely undescribed.

METHODS

We performed a multicenter retrospective cohort study of children with neutropenia within the first 180 days after kidney transplant. Multivariable linear regression and Poisson regression were used to assess duration of neutropenia and incidence of hospitalization, infection, and rejection.

RESULTS

Of 341 neutropenic patients, 83 received G-CSF during their first episode of neutropenia. Median dose of G-CSF was 5 mcg/kg for 3 (IQR 2-7) doses. G-CSF use was associated with transplant center, induction immunosuppression, steroid-free maintenance immunosuppression, hospitalization, and decreases in mycophenolate mofetil, valganciclovir, and trimethoprim-sulfamethoxazole dosing. Absolute neutrophil count nadir was also significantly lower among those treated with G-CSF. G-CSF use was not associated with a shorter duration of neutropenia (p = .313) and was associated with a higher rate of neutropenia relapse (p = .002) in adjusted analysis. G-CSF use was associated with a decreased risk of hospitalization (aIRR 0.25 (95%CI 0.12-0.53) p < .001) but there was no association with incidence of bacterial infection or rejection within 90 days of neutropenic episode.

CONCLUSION

G-CSF use for neutropenia in pediatric kidney transplant recipients did not shorten the overall duration of neutropenia but was associated with lower risk of hospitalization. Prospective studies are needed to determine which patients may benefit from G-CSF treatment.