title: Drug-induced immune-mediated thrombocytopenia in the intensive care unit.
abstract: A 62-year-old woman with prosthetic mitral valve was admitted for explant of an infected prosthetic knee. Perioperatively, she was bridged with heparin and started on empiric vancomycin and piperacillin-tazobactam. Platelet counts dropped precipitously within 2 days reaching a nadir of 6000/μL, without any bleeding. Decline persisted despite substituting heparin with bivalirudin. Antiplatelet factor 4 and anti-PLA1 antigen were negative. Schistocytes were absent. Antibiotics were substituted with daptomycin for suspected drug-induced thrombocytopenia. Pulse dose of intravenous immunoglobulin was initiated with rapid normalization of platelet count. She tested positive for IgG antiplatelet antibodies to vancomycin and piperacillin-tazobactam thereby confirming the diagnosis. Drug-induced immune-mediated thrombocytopenia is an underrecognized cause of thrombocytopenia in the intensive care units. Clinicians should be cognizant of this entity, and a definitive diagnosis should be sought if feasible.
authors.affiliation: Critical Care Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. Electronic address: somnathbose@gmail.com.
authors.forename: Somnath
authors.initials: S
authors.lastname: Bose
authors.affiliation: Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. Electronic address: wurme@ccf.org.
authors.forename: Ellen
authors.initials: E
authors.lastname: Wurm
authors.affiliation: Surgical Critical Care Unit, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. Electronic address: popovim@ccf.org.
authors.forename: Marc J
authors.initials: MJ
authors.lastname: Popovich
authors.affiliation: Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA. Electronic address: silverb@ccf.org.
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Silver
mesh_terms: D020878:Device Removal; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000276:immunology; D007362:Intensive Care Units; D008875:Middle Aged; D010397:Penicillanic Acid / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D010878:Piperacillin / Q000008:administration & dosage / Q000009:adverse effects; D000077725:Piperacillin, Tazobactam Drug Combination; D016459:Prosthesis-Related Infections / Q000601:surgery; D016553:Purpura, Thrombocytopenic, Idiopathic / Q000139:chemically induced* / Q000175:diagnosis / Q000276:immunology; D014640:Vancomycin / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D007074:Immunoglobulin G; D000077725:Piperacillin, Tazobactam Drug Combination; D014640:Vancomycin; D010397:Penicillanic Acid; D010878:Piperacillin
keywords: Drug induced thrombocytopenia; Immune mediated thrombocytopenia; Intensive care unit; Piperacillin; Thrombocytopenia; Vancomycin