Levetiracetam
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Pancytopenia: case report A 32-year-old man developed pancytopenia during prophylactic treatment with levetiracetam. The man was brought to the emergency department in an unconscious state. He fell on the ground six hours prior following a punch to his right temple. On examination, his Glasgow Coma Scale score was 8, with aniscoria and left sided hemiplegia. Following resuscitation and urgent imaging, he underwent a right sided craniotomy and a large parietotemporal extra-dural haematoma evacuated. Prior to the surgery, he had received loading dose of levetiracetam 1g [route not stated] as prophylaxis. Postoperatively, he was scheduled to receive 500mg twice daily for 7 days as per institution protocol. Biochemistry prior to surgery was unremarkable; haemoglobin, WBC, platelets, INR, activated partial thomboplastin time, renal and hepatic function were all normal. Repeat haemoglobin levels were found to be decreased immediately post-operatively. On post-operative day 1, repeat imaging demonstrated almost complete resolution of haematoma and the pupils were equal and reactive to light. Haemoglobin levels were found to be further decreased. On post-operative day 3, his haemoglobin levels were found to be remarkably decreased. He was tachycardic despite adequate fluid volume. A unit of packed RBCs was administered. His platelet count, neurtrophils, lymphocytes, monocytes, eosinophils and basophils were found to be decreased. The decline in levels of these parameters were suggestive of bone marrow suppression. He again received a single unit of packed RBCs, following which his haemoglobin levels slightly increased. He did no have any signs of gastrointestinal bloods loss, haematuria or haemorrhage. There was no evidence of occult gastrointestinal bloods loss, haematuria or external signs of haemorrhage at bedside examination. There were no features of infection; his septic screen was negative. Peripheral blood smear did not reveal any schistocytes or blood cell abnormality. His renal and hepatic function as well as haptoglobin and lactate dehydrogenase levels were found to be normal. Haematinics showed normal stores of ferritin, B12 and folate; however, his plasma ferritin and plasma transferrin was found to be low. A CT scan of his abdomen and pelvis demonstrated no evidence of intra-abdominal bleeding or solid organ injury. The differential diagnoses included disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and infection. Given investigations were otherwise unremarkable, the possibility of a drug side effect was considered. The man’s therapy with levetiracetam was stopped on post-operative day 4. Levetiracetam level was not taken because a dosedependent mechanism was unlikely and there was no clear indication to continue the drug. The next day, his haemoglobin, WBC count, neutrophils and platelets levels were found to be increased. His tachycardia had settled, with no clinical signs of anaemia and he was neurologically intact with a normal cognition. Blood counts showed a continuous im
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