SEVERE VANCOMYCIN-INDUCED THROMBOCYTOPENIA IN A 53-YEAR-OLD WOMAN

Vankomicin i drugi lijekovi mogu se previdjeti kao uzrok trombocitopenije kod kritičnih bolesnika kod kojih su sepsa, heparinom izazvana trombocitopenija i diseminirana intravaskularna koagulopatija češći uzroci. U radu je prikazan slučaj teške trombocitopenije kod 53-godišnje bolesnice podvrgnute hitnoj laparotomiji zbog difuznog peritonitisa koja se razvila 24 sata nakon uvođenja terapije vankomicinom. Broj trombocita prije terapije vankomicinom iznosio je 101 x 109/L, a nakon 2 doze broj je pao na 8 x 109/L bez kliničkih znakova krvarenja. Višestruke transfuzije trombocita podigle su broj trombocita najviše do 48 x 109/L. Vankomicin je isključen iz terapije kao mogući uzrok trombocitopenije, a uveden je ciprofl oksacin. U serumu bolesnice dokazana su IgG antitrombocitna antitijela i uveden je u terapiju metilprednizolon 40 mg/dan. Stanje bolesnice i broj trombocita postepeno su se popravljali te je preoperativna vrijednost trombocita postignuta 10 dana nakon ukidanja vankomicina. Nalaz antitrombocitnih antitijela ovisnih o vankomicinu potvrđuje dijagnozu vankomicinom izazvane trombocitopenije, ali je test dostupan samo u specijaliziranim laboratorijima.Vancomycin and other drugs are often overlooked as causes of thrombocytopenia in critically ill patients in whom sepsis, heparin-induced thrombocytopenia and disseminated intravascular coagulation are considered as more common causes. We report a case of profound vancomycin-induced thrombocytopenia developing within 24 hours of treatment initiation. A 53-year-old woman with no signifi cant comorbidities underwent laparoscopic surgery for a left-sided ovarian tumor. Two days later, she developed severe sepsis with symptoms and signs of acute abdomen. Emergency laparotomy revealed a lesion of the sigmoid colon and fi brinopurulent peritonitis. Empirical antibiotic therapy started intraoperatively included i.v. metronidazole and gentamicin. On postoperative day 2, it was changed to i.v. meropenem and vancomycin according to the results of microbiological analysis of intraoperatively obtained abdominal fl uid and blood cultures. On the day vancomycin was started, platelet count was 101 x 109/L, falling to 8 x 109/L after two doses of vancomycin, with no clinical signs of bleeding. Vancomycin was excluded from therapy as a potential cause of thrombocytopenia and ciprofl oxacin was introduced. Multiple platelet transfusions elevated the count to a peak of just 48 x 109/L. IgG antiplatelet antibodies were detected in the patient’s serum and methylprednisolone 40 mg i.v. was added to therapy. The patient’s condition improved and she was discharged from the Intensive Care Unit on postoperative day 9 with platelet count of 50 x 109/L. The count returned to the preoperative value 10 days after discontinuation of vancomycin. In conclusion, vancomycin can cause severe thrombocytopenia and should be discontinued from therapy after more common causes have been excluded. Vancomycin dependent antibodies can be detected in some specialized laboratories, but these tests are not widely available