Isolated severe thrombocytopenia in the setting of extreme hyperthermia
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LETTER TO THE EDITOR
Isolated severe thrombocytopenia in the setting of extreme hyperthermia Robert Stuver 1
&
Prateek Khanna 1 & Jonathan W. Wischhusen 1 & Celia Cobb 1 & Bruno Bockorny 1
Received: 23 June 2020 / Accepted: 16 August 2020 / Published online: 20 August 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor, Herein, we present a patient with profound thrombocytopenia in the setting of extreme hyperthermia from amphetamine overdose. Platelets normalized with cooling. A 42-year-old male presented with encephalopathy. He was in his normal health until the previous night when he ingested an unknown quantity of prescription medication. His wife found him moaning and acting bizarrely. He had opened their windows and removed his clothing. He had a history of ADHD and abuse of amphetamines. His only prescribed medications were lisdexamfetamine and valproic acid. Initial temperature was 43 °C. Cooling with ice and bladder irrigation was initiated. Examination showed no trauma, normal muscle tone, and intact reflexes. There was no bleeding, bruising, or petechiae. The leukocyte count was 12,800 per cubic millimeter (mm3), hemoglobin 14.1 g per deciliter (dL), and platelets 350,000 per mm 3 . Prothrombin (PT) and partial thromboplastin (PTT) times were 14.1 and 32.6 seconds, respectively. Total bilirubin was 0.7 mg per dL and creatinine kinase was 27,620 U/L. Urine was positive for amphetamines. Comprehensive toxicology screen was otherwise negative for valproic acid, lithium, barbiturates, opiates, cocaine, ethanol, tricyclic antidepressants, ethylene glycol, and salicylates. Six hours after admission, platelets decreased to 55,000/ mm3. Twelve hours after admission, platelets decreased to 31,000/mm3. A nadir of 16,000/mm3 was reached after 30 h. The leukocyte count, hemoglobin, PT, and PTT remained stable throughout this time. No medications had been started,
* Robert Stuver [email protected] 1
Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, USA
and the patient had no heparin exposure. There was no infection. Peripheral blood smear showed no clumping, giant platelets, schistocytes, or abnormal white or red cell forms (Fig. 1). The presentation was inconsistent with immune thrombocytopenic purpura or a microangiopathic process. In the absence of other etiology, thrombocytopenia was attributed to hyperthermia. He reached normothermia within 24 hours. Platelets remained less than 30,000/mm3 until day six when they abruptly increased to 78,000/mm3 without transfusion or steroids. This increase continued, and platelets reached 344,000/ mm3. He recovered and was discharged. The effects of hyperthermia on platelets have been noted previously in cases of heat stroke and whole body hyperthermia treatments for malignancy [1, 2]. More recently, thrombocytopenia has been noted as a finding in febrile viral syndromes [3, 4]. In some cases, thrombocytopenia is associated with bleeding with disseminated intravascular coagulation (DIC), whereas in other cases, it is an iso
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