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A6928 - Rapid Near-Fatal Piperacillin/Tazobactm-Induced Thrombocytopenia
Author Block: R. Masroujeh, B. Bonder, A. Mandviwala, A. Haj Abdulkader; Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
Introduction: Thrombocytopenia is a common problem in ICU. Drug-induced thrombocytopenia (DITP) is one of the under-recognized causes of thrombocytopenia. We report a case of severe rapid life-threatening DITP that occurred two hours after exposure to Piperacillin/Tazobactam (TZP) leading to massive hemoptysis.
Case: A 20-year-old man with history of IV drug abuse underwent tricuspid valve replacement for MSSA endocarditis with post-operative course complicated by Pseudomonas and Stenotrophomonas pneumonia. The patient was initiated on TZP and his platelet count dropped to 2 thousand/µL 9 days following TZP initiation with mild epistaxis. Workup showed no evidence of microangiopathic hemolytic anemia or heparin-induced thrombocytopenia. DITP was suspected, so pantoprazole and TZP were stopped. Platelets increased to 43 thousand/µL following discontinuation, and bleeding subsided. Unfortunately, TZP and Pantoprazole were not added to patient’s allergy list prior to transfer out of ICU. One week later, he spiked fever and TZP was empirically restarted. Two hours following first dose administration, the patient developed massive hemoptysis and hypoxemic respiratory failure requiring endotracheal intubation. He also started bleeding from healing surgical wound and a previously placed chest tube. Urgent labs showed platelet counts of 1 thousand/µL down from 198 thousand/µL earlier that day. Patient continued to desaturate despite high ventilatory support (FiO2 100% and PEEP 14) with continued hemoptysis. Platelets were transfused urgently, pulse methylprednisolone, and intravenous immunoglobulin (IVIG) were administered. Subsequently, he was placed on venovenous ECMO, to maintain oxygenation. Over the following 3 days, platelet counts improved and ECMO was discontinued. He was eventually discharged to a nursing facility 10 day following this event.
Discussion: TZP is one of the most commonly used drugs in ICU, given its broad spectrum and favorable safety profile. DITP is usually a gradual phenomenon occurring several days following exposure to a medication. However, re-exposure can cause a severe rapid reaction secondary to pre-existing antibodies. In this case, the rapid and profound drop in platelets and the massive bleeding resultant from the erroneous administration of TZP was remarkable. It is also unique in that ECMO was utilized in the setting of profound thrombocytopenia, a relative contraindication. Low index of suspicion, rapid review of recent drug exposures, prompt administration of immune suppression, and aggressive supportive care led to a favorable outcome in this patient’s case.