Paracetamol
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Agranulocytosis in an elderly patient with lymphoma: case report A 73-year-old man developed agranulocytosis during treatment with paracetamol; he was later found to have angioimmunoblastic T-cell lymphoma (AILT). The man presented with erythema and general fatigue in late June 2007, and started receiving paracetamol [acetaminophen; dosage not stated], aspirin, cefaclor and other treatments. During the first half of the following month, he developed fever of 39°C and loss of appetite. All medications were discontinued, but his fever and chills worsened, and he was hospitalised for agranulocytosis. On admission, he had a body temperature of 38.3°C, slight conjunctival pallor, and multiple palpable lymph nodes on his neck, right armpit and right inguinal area; the liver was palpable, and he had extensive erythema on his trunk, arms and legs. Laboratory investigations revealed a WBC count of 1400/µL (0% neutrophils, 18% atypical lymphocytes), a mildly decreased platelet count, anaemia, high levels of hepatobiliary enzymes, ferritin, IgG and soluble interleukin 2 receptor, and a γ-globulin fraction of 35.5%. A CT scan disclosed mediastinal and abdominal lymphadenopathy, hepatomegaly and mild pleural effusion. Bone marrow investigation yielded the following findings: neutrophil system cells 11%, mature neutrophils 1%, erythroblasts 13%, mononuclear cells 13% and atypical lymphocytes 15%. Drug-induced agranulocytosis was suspected. He started receiving filgrastim and antibiotics immediately after admission. Agranulocytosis and his rash had improved on day 4, but his fever persisted. The man again received paracetamol [dosage not stated] on day 12. His fever persisted, his rash reappeared and, on day 19, agranulocytosis also recurred. Findings from a lymph node biopsy on day 18 were consistent with AILT. CHOP chemotherapy was initiated on day 19 with resolution of fever, improvement of lymphadenopathy and disappearance of lymphoma cells in his blood; haemolytic anaemia and his rash improved. Therapy was changed to ESHAP chemotherapy from day 47, and to ciclosporin from day 72. The latter was eventually withdrawn due to infection, but a good treatment response was maintained with prednisolone, vincristine, bleomycin, cytarabine and methotrexate. Author comment: We cannot rule out that the agranulocytosis was AILT-associated autoimmune neutropenia, nor the possibility of hemopoietic impairment caused by AILT bone marrow infiltration. However, as G-CSF recovered on stopping the drugs and recurrence was rapid on restarting acetaminophen, we are inclined to think it was drug-induced. Inoue D, et al. Angioimmunoblastic T-cell lymphoma complicated by recurrent drug-induced agranulocytosis. Rinsho Ketsueki 50: 87-91, No. 2, Feb 2009 801158135 [Japanese; summarised from a translation.] - Japan
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Reactions 9 Jan 2010 No. 1283
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