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JURNAL

This case report describes a young woman who developed thrombocytopenia while being treated for pulmonary tuberculosis with anti-tuberculosis drugs. She was given the standard four-drug regimen, which included rifampicin. A few days later, she had black tarry stools and lab tests showed worsening anemia and decreased platelet count. Rifampicin was identified as the likely cause and discontinued. Her condition improved after removal of rifampicin from her treatment. She later underwent rifampicin desensitization and was able to tolerate reintroduction of rifampicin at a gradual increased dose while continuing her full tuberculosis treatment course without further bleeding issues.

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rike apriliana
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19 views

JURNAL

This case report describes a young woman who developed thrombocytopenia while being treated for pulmonary tuberculosis with anti-tuberculosis drugs. She was given the standard four-drug regimen, which included rifampicin. A few days later, she had black tarry stools and lab tests showed worsening anemia and decreased platelet count. Rifampicin was identified as the likely cause and discontinued. Her condition improved after removal of rifampicin from her treatment. She later underwent rifampicin desensitization and was able to tolerate reintroduction of rifampicin at a gradual increased dose while continuing her full tuberculosis treatment course without further bleeding issues.

Uploaded by

rike apriliana
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Thrombocytopenia in Young

Patient due to Anti Tuberculosis


Drugs : A Case Report

By : Rike Apriliana
Preseptor : dr. Nurfitri, Sp.P
Background
• Most anti-tuberculosis (ATD) drugs are
relatively safe, but unusual serious reactions
can occur.
• Thrombocytopenia is an uncommon but
potentially life-threatening complication of
certain ATDs and is characterized by rapid
destruction of platelets whenever an offending
drug is taken by a susceptible person.
• Rifampicin is the most common cause of
thrombocytopenia.
INTRODUCTION
• Tuberculosis (TB) is a global health problem
• TB treatment has been a therapeutic
challenge for a long time.
• Rifampicin -induced thrombocytopenia was
first reported in 1970.
This study is a case report of a woman, who
came with shortness of breath, that was
further diagnosed as pulmonary TB and
received category one of ATD. In her progress,
thrombocytopenia was developed and lead to
bleeding manifestation as melena
CASE
• A patient was admitted to Dr. Soetomo
General Hospital on July 13th, 2016,
• with chief complaint as shortness of breath.
• This complaint had occurred for one week and
worsened two days before admission.
• Productive cough had appeared since two
months before admission
• with a change of sputum from white to
yellowish one week before admission.
• The patient also mentioned a subfebrile
condition during this period.
• There were also enlargement of lymph nodes
in the left and right side of the neck that was
known two days before admission.
• There were also loss of appetite, night sweats,
and unintentional weight loss.
• The patients were 22 days following after
giving birth when admitted, and puerperal
bleeding still occurred
• Physical examination showed four
enlargements of lymph nodes in the right and
left side of the neck, sized ± 1.5 cm x 1.2 cm x
1 cm, without any tenderness.
• Vocal fremitus was decreased in 1/3 lower of
right and left lungs. In auscultation, there was
diminished vesicular breath sound in 1/3
lower of right and left lungs.
Chest Radiology

Bilateral pleural effusions and infiltrates in both lungs on July 13th, 2016
On July 14th, 2016, category 1 ATD
(INH 200 mg, Rifampicin 450 mg, Pirazinamid
1000 mg, Ethambutol 750mg) was provided to
the patient without any additional symptom.
On July 15th, 2016, sputum acid-fast bacillus
(AFB) smear test and gram smear test were
performed. The results of these tests were
BTA 2+ without any gram-positive or –negative
bacteria.
On July 16th, 2016
• The patient defecated a black and tarry stool in a
considerable amount.
• The patient was seen pale while physical examination
showed anemic conjunctiva.
• The patient was administered tranexamic acid 1 gram
and vitamin K intravenously every 8 hours, omeprazole
40 mg intravenously every six hours, and a tablespoon
of oral sucralfate every 8 hours.
A laboratory study
• showed a worsen anemia from the previous
test (Hb 7.5 g/dL) became 5.4 g/dL, Although
the patient had received 2 packs of PRBC.
• The thrombocyte level also decreased from
200 000/µL to 90 700 /µL,
• while the level of leukocytes and neutrophile
showed an improvement
The underlying cause of melena and
thrombocytopenia was evaluated and
consulted to Division of Tropical Infection
for any thrombocytopenia condition
associated with drugs, which was given to
the patient during treatment for CAP and
pulmonary TB.
• It was suggested to discontinue Rifampicin as
it was the most suspected to induce
thrombocytopenia in the patient.
• The remaining therapy proceeded, and ATD
regimen was provided without Rifampicin.
Chest radiography on July 18th, 2016 showed less
infiltration in both lungs with organized bilateral pleural
effusions
CBC was also performed on July 23th, 2016 to
evaluate Hb level following PRBC transfusion
as well as thrombocyte level of the patient.
Laboratory test showed improvements as
follows: Leukocytes (18.9x103/uL), neutrophil
62.4%, Hb 10.9 g/dL, HCT 34.8%, and PLT
563x103/uL.
Outpatient Stage
• Clinical evaluation and Rifampicin
desensitization were performed in DOTS
outpatient clinic of Dr. Soetomo General
Hospital.
• The patient was given Rifampicin gradually
from 1/3 dosage, raised slowly every three
days to 2/3 dosage, and finally, full dosage.
• The first densitazation was performed on August
2nd, 2016. The patient was given Rifampicin 150
mg for three days consecutively
• Result of laboratory test on August 5th, 2016, was
leucocytes (6.51x103/uL), neutrophil 71.2%, Hb
10.4 g/dL, HCT 32.8%, PLT 362x103/uL.
• There was no thrombocytopenia on CBC test and
no symptom of any bleeding..
• Desensitazation proceeded with prescribed
Rifampicin 300 mg and then full dosage, 450 mg
• clinical evaluation, there was no sign of bleeding
and laboratory test on August 10th 2016 showed
normal
• Levofloxacin was discontinued, and Rifampicin
was prescribed again as category one of ATD.
• The patient continued her TB treatment in
Community Health Care of Sepanjang.
• AFB smear test evaluation at the end of the
second month of the treatment showed a
conversion to negative.
• There was no symptom of bleeding on the
second phase, which was a phase consisted of
Rifampicin and Isoniazid consumed thrice a
week
DISCUSSION
Thrombocytopenia is defined as a disorder, which
showed an abnormality on the low amount of
thrombocyte.

• Thrombocytopenia is classified mild if the amount was


between 70 - 150 × 103 per uL (70 - 150 × 109 per L),
• Moderate if it was 20 - 70× 103 per uL (20 × 109 per L),
• Severe if less than 20 × 103 per uL (20 × 109 per L)
Etiology
Thrombocytopenia could emerge because of :
• decreased production of thrombocytes
• increased platelet consumption
• sequestration
Classification Mechanism Incidence Example of Drugs
Hapten links Penicillin, possibly
Hapten-dependent caovalently to Very rare some
membrane protein and cephalosporin
antibody induces drug antibiotics
specific immune
response
A study by Karl Landsteiner in immunochemistry field in 1930 showed that a small
molecule, such as drugs, organic compounds, peptides, and oligosaccharides, with
molecular weight less than 2-5 kDa could not induce any immune response. Vice
versa, these small molecules, which are called haptens, could produce an immune
response when they are on covalently bound with their carrier protein
Clinical criteria (George criteria) had been
established to implicate a drug, which had
been suspected of inducing thrombocytopenia,
as following:

• Exposure of the candidate drug prior to


thrombocytopenia. 
• Fully and sustainable improvement of
thrombocytopenia after discontinuation of the
candidate drug.
• The suspected drug is the only drug used
prior to thrombocytopenia, or if other agents
were proceeded or reintroduced after
discontinuation of the alleged agents, then
the level of thrombocytes is normal and
sustainable. Rule out other thrombocytopenia
inducer.

• Re-exposure with candidate drugs will result


in refractory thrombocytopenia
The evidence is considered valid if criteria 1, 2,
3, and 4 are met; Probable if criteria 1, 2, and
3 are fulfilled; Possible if only 1 criterion is
fulfilled; and Unlikely if there is no fulfilment
criteria
Onset DIPT
• The average onset of thrombocytopenia
occurred 1-2 weeks following the exposure of
the suspected drug
CONCLUSION
Even though it is often complicated by
various potential etiology of
thrombocytopenia, the suspected drug
isolation and cessation on a patient in
acute condition must be adequately
performed and organized, as if the
treatment continues, it could lead to fatality.
• On the other hand, restricting some primary
suspected agents could lead to a medical
treatment limitation.
• The clinical challenge in drug-induced
thrombocytopenia is identifying the
suspected agent as fast and as early as the
disorder occurs so that the right management
could be started while hindering bleeding
complications.
THANK YOU

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