Agranulocitosis febril y artropatía reactiva asociada a consumo de cocaína en un paciente HLA B27 positivo / Febrile agranulocytosis and reactive arthropathy associated with cocaine consumption in an HLA B27 positive patient

Resumen La agranulocitosis asociada al consumo de cocaína es un fenómeno vinculado a la presencia de levamisol, un agente antihelmíntico e inmunomodulador, usado como adulterante de la cocaína. Esta reacción puede presentarse con mayor frecuencia en personas con HLA B27. Además de la agranulocitosis, las personas que consumen cocaína adulterada con levamisol pueden desarrollar fiebre, lesiones en piel, artralgias y, menos frecuentemente, artritis y entesitis inflamatoria. Presentamos el caso de un paciente consumidor de cocaína, con genotipo HLA B27, que desarrolló agranulocitosis febril y artropatía reactiva. En sangre se detectó la presencia de ANCA p, ANCA atípico y MPO, y fueron excluidas otras causas de agranulocitosis. Fue tratado con corticoides y posteriormente metotrexato, terapia de deshabituación, con buena evolución.

Abstract Agranulocytosis associated with cocaine use is a phenomenon linked to the presence of levamisole, an anthelminthic and immunomodulating agent, used as an adulterant to cocaine. This reaction has been associated with the presence of HLA B27. In addition to agranulocytosis, people who use levamisole-adulterated cocaine may develop fever, skin lesions, arthralgias, and less frequently, inflammatory enthesitis and arthritis. We present the case of a cocaine-consuming patient with HLA B27 genotype, who developed febrile agranulocytosis and inflammatory arthropathy. The presence of p ANCA, atypical ANCA and MPO was detected in blood, and other causes of agranulocytosis were excluded. He was treated with corticosteroids and later methotrexate, therapy for addiction, with good evolution.

Propylthiouracil-induced agranulocytosis as a rare complication of antithyroid drugs in a patient with Graves' disease

SUMMARY INTRODUCTION: Graves' disease (GD) is an autoimmune disorder characterized by hyperthyroidism. Antithyroid drugs (ATDs) are available as therapy. Agranulocytosis is a rare but potentially fatal complication of this therapy. In this study, we report agranulocytosis induced by propylthiouracil (PTU) in a patient with GD and the difficulties of clinical management. CASE: RNBA, male, 30 years old, with GD, treated with propylthiouracil (PTU). He progressed with pharyngotonsillitis. Then, PTU was suspended and antibiotic, filgrastim, propranolol, and prednisone were initiated. Due to the decompensation of hyperthyroidism, lithium carbonate, dexamethasone, and Lugol's solution were introduced. Total thyroidectomy (TT) was performed with satisfactory postoperative progression. DISCUSSION: We describe here the case of a young male patient with GD. For the treatment of hyperthyroidism, thioamides are effective options. Agranulocytosis induced by ATDs is a rare complication defined as the occurrence of a granulocyte count <500/mm3 after the use of ATDs. PTU was suspended, and filgrastim and antibiotics were prescribed. Radioiodine (RAI) or surgery are therapeutic alternatives. Due to problems with ATD use, a total thyroidectomy was proposed. The preoperative preparation was performed with beta-blocker, glucocorticoid, lithium carbonate, and Lugol solution. Cholestyramine is also an option for controlling hyperthyroidism. TT was performed without postoperative complications. CONCLUSION: Thionamide-induced agranulocytosis is a rare complication. With a contraindication to ATDs, RAI and surgery are definitive therapeutic options in GD. Beta-blockers, glucocorticoids, lithium carbonate, iodine, and cholestyramine may be an adjunctive therapy for hyperthyroidism.

RESUMO INTRODUÇÃO: A doença de Graves (DG) é uma doença autoimune caracterizada por hipertireoidismo. As drogas antitireoidianas (DAT) são opções terapêuticas disponíveis. A agranulocitose é uma complicação rara, potencialmente fatal desta terapia. Neste estudo, relatamos um caso de agranulocitose induzida por propiltiouracil (PTU) em paciente com DG e as dificuldades do manejo clínico. RELATO DE CASO: RNBA, sexo masculino, 30 anos, com DG, tratado com PTU. Evoluiu com faringoamigdalite, sendo o PTU suspenso e antibióticos, filgrastim, propranolol e prednisona, iniciados. Devido à descompensação do hipertireoidismo, iniciou carbonato de lítio (CL), dexametasona e a solução de Lugol. A tireoidectomia total (TT) foi realizada com boa evolução pós-operatória. DISCUSSÃO: Descrevemos caso de paciente jovem, sexo masculino, com DG. Para o tratamento do hipertireoidismo, as tionamidas são opções efetivas. A agranulocitose induzida por DATs é uma complicação rara, definida como a ocorrência de contagem de granulócitos <500/mm3 após uso de dats. PTU foi suspenso e foram prescritos filgrastim e antibiótico. O radioiodo (RAI) ou a cirurgia são alternativas terapêuticas. Devido a problemas com o uso de DAT, a TT foi proposta. A preparação pré-operatória foi realizada com betabloqueador, glicocorticoide, CL e solução de Lugol. A colestiramina também é uma opção para controlar o hipertireoidismo. A TT foi realizada sem complicações pós-operatórias. CONCLUSÃO: A agranulocitose induzida por drogas antitireoidianas é uma complicação rara. Com a contraindicação às DATs, RAI e cirurgia são opções terapêuticas definitivas para DG. Os betabloqueadores, glicocorticoides, CL, iodo e a colestiramina podem ser uma terapia adjuvante para o hipertireoidismo.

Agranulocitosis por levamisol asociado a cocaína / Agranulocytosis induced by levamisole in association to cocaine

La neutropenia en usuarios de cocaína es una condición de reciente reconocimiento en distintos países. Se debe a la utilización del levamisol, una antigua droga antiparasitaria e inmunomoduladora, como agente de corte. Presentamos el caso de un paciente con agranulocitosis por levamisol asociado a cocaína y una revisión de las características del cuadro, así como del control de estos pacientes. También se tratan los motivos vinculados al agregado cada vez más frecuente de levamisol a la cocaína. Este es el primer caso descrito en nuestro país, si bien es probable que existan muchos casos no reconocidos o no comunicados de esta enfermedad.

Agranulocytosis in cocaine users is a worldwide recently recognized condition. It is due to the utilization as cutting agent of levamisole, an ancient antiparasitic and immunomodulator drug. We describe the case of a patient with agranulocytosis induced by levamisole in association to cocaine and we review clinical and biochemical characteristics of the clinical picture, as well as the management of these patients. We also analyze the reasons related to a more and more frequent practice, the addition of levamisole to cocaine. This is the first case described in our country, although it is probable that there are many not recognized or not described cases related to this pathology.

Postinfectious Guillain-Barre syndrome in a patient with methimazole-induced agranulocytosis

Both Graves disease and Guillain-Barre syndrome (GBS) are autoimmune disorders caused by impaired self-tolerance mechanisms and triggered by interactions between genetic and environmental factors. GBS in patients who suffer from other autoimmune diseases is rarely reported, and the development of postinfectious GBS in a patient with Graves disease has not been previously reported in the literature. Herein, we report a patient with Graves disease who developed postinfectious GBS during a course of methimazole-induced agranulocytosis.

Agranulocitose induzida por dapsona em paciente com hanseníase: relato de caso / Dapsone-mediated agranulocytosis in a patient with leprosy: case report

JUSTIFICATIVA E OBJETIVOS: A dapsona é um medicamentode uso amplo, entre os quais se inclui o tratamento da hanseníase. A agranulocitose é descrita como uma reação adversa desse medicamento, embora seja rara e imprevisível. O objetivo deste estudo foi relatar um caso de agranulocitose induzida por dapsona em paciente com hanseníase.RELATO DO CASO: Paciente do sexo feminino, 56 anos, admitida no pronto-atendimento, com história e exame físico compatíveis com amigdalite com início há quatro dias, bem como dor torácica e dispneia. Estava em tratamento de hanseníase com clofazimina e dapsona havia dois meses. O hemograma revelava anemia (hemoglobina = 9,3 g%), leucopenia (800/mm3 - 1% segmentados, 98% linfócitos e 1% monócitos) plaquetopenia (144.000/mm3), e reticulocitose (2,5% ou 87.750/mm3). Os exames de imagem não demonstraram alterações. Diante do quadro, foi suspenso o tratamento com dapsona e realizado antibioticoterapia por via venosa e terapia com fator estimulador de colônia de granulócitos. A paciente teve melhora clínica significativa,recebendo alta no 20° dia de internação hospitalar para acompanhamento ambulatorial.CONCLUSÃO: Considerando que o risco de desenvolvimento da agranulocitose é muito pequeno, ele não deve, em geral, ser um fator importante na decisão sobre o uso da dapsona em pacientes com hanseníase. Entretanto, devem-se conhecer suas manifestações e logo que identificada realizar a terapêutica adequada.(AU)

BACKGROUND AND OBJECTIVES: Dapsone is a drug with many uses, including the treatment of leprosy. Agranulocytosisis described as an adverse reaction of this drug, in spite of being rare and unpredictable. This study has the objective of reporting a case of agranulocytosis mediated by dapsone in a patient with leprosy.CASE REPORT: Female patient, 56-year-old, who presented to the emergency department with clinical history and examination suggestive of tonsillitis within 4 days of onset as well as chestpain and dyspnea. She was in treatment of leprosy with clofazimine and dapsone for 2 months. The complete blood count showed anemia (hemoglobin = 9.3 g%), leukopenia (800/mm3 - 1% neutrophil granulocytes, 98% lymphocytes and 1% monocytes) thrombocytopenia (144.000/mm3), and reticulocytosis(2,5% or 87.750/mm3). The imaging studies have not shown anyabnormalities. The treatment with dapsone was withdrawn and it was started therapy with intravenous antibiotics and granulocytecolony-stimulating factor. The patient had significant clinical improvement,and was discharged for outpatient treatment in the 20th day of hospital admission.CONCLUSION: Considering that the risk of developing agranulocytosisis very low, it should not be, usually, an importantfactor for the decision of using dapsone in patients with leprosy.Nonetheless, its manifestations must be known and, as soon as this complication is identified, the adequate therapy must be provided.(AU)

Toxic epidermal necrolysis and agranulocytosis: Rare adverse effects of ciprofloxacin.

Ciprofloxacin is one of the most commonly used antibacterial agents with relatively few side effects. Serious adverse reactions reported with ciprofloxacin are rare with an incidence of 0.6%. Recently we came across two rare adverse effects of ciprofloxacin, viz. toxic epidermal necrolysis and agranulocytosis. To our knowledge, a total of seven cases have been reported in the literature documenting an association between oral ciprofloxacin administration and toxic epidermal necrolysis. One case of granulocytopenia, four of pancytopenia and fifteen of leucopenia worldwide have been reported. With the use of ciprofloxacin becoming more and more widespread, these two rare but fatal complications of ciprofloxacin should be borne in mind.

Mucormicosis en un paciente con agranulocitosis secundaria a metimazol: informe de un caso / Case report of mucormycosis in a patient with secondary methimazole-induced agranulocytosis

La agranulocitosis es una complicación poco frecuente de los medicamentos antitiroideos, se presenta en menos de 0.5% de los pacientes en los primeros meses de tratamiento. Se considera el efecto adverso más grave de estos medicamentos, ya que se puede complicar con infecciones severas con una tasa alta de mortalidad. La mucormicosis es una infección micótica severa observada en huéspedes inmunocomprometidos como pacientes con diabetes, neoplasias hematológicas o con tratamiento inmunosupresor; sin embargo, la asociación de mucormicosis con agranulocitosis por metimazol no se ha reseñado previamente. El objetivo de este informe es analizar el caso de una mujer con bocio tóxico difuso y agranulocitosis asociada a metimazol, quien desarrolló mucormicosis rinopalatina.

Agranulocytosis is a rare side effect of antithyroid drugs, it occurs in less than 0.5% of patients, usually during the first few months of treatment. It is considered to be the most serious adverse effect of these medications since it may be complicated by serious, life-threatening infections. Mucormycosis is a severe mycotic infection that usually develops in immunocompromised hosts, such aspatients with diabetes mellitus, hematologic malignancies or immunosuppressive therapy. The association of mucormycosis with methimazole-induced agranulocytosis has not been previously described. The objective of this case presentation is to analyze the case ofa woman with diffuse toxic goiter and methimazole-induced agranulocytosis who developed rhino-palatal mucormycosis.

Agranulocytosis induced by multidrug therapy in leprosy treatment: a case report

Multidrug therapy (WHO/MDT) in multibacillary leprosy consists of treatment with rifampicin, dapsone andclofazimine. However, adverse effects can cause the patient to abandon treatment. We report on a patient whopresented agranulocytosis and hemolytic anemia associated with this treatment regime. We also examined theimportance of laboratory exams for diagnosis and follow-up of the patient, and for early detection of adverse effects, with a view to improving adhesion to treatment and contributing to the eradication of Hansen’s disease as a public health issue.

The incidence of clozapine-induced leukopenia in patients with schizophrenia at Srinagarind Hospital.

OBJECTIVE: Define the incidence of clozapine-induced leukopenia, neutropenia, and agranulocytosis in patients with schizophrenia at Srinagarind Hospital. MATERIAL AND METHOD: A descriptive study was done by retrospective reviews of the medical records of schizophrenic outpatients at psychiatric clinic in Srinagarind Hospital who had received clozapine from January 1st, 2003 to December 31st, 2005. The demographic data, incidence rate, and incidence density of leukopenia, neutropenia, and agranulocytosis were collected. RESULTS: One hundred and seventeen medical records were reviewed, 65 patients met the inclusion criteria. One patient developed neutropenia. The incidence rate of neutropenia was 1.5% and the incidence density of neutropenia was 0.01/year. No leukopenia or agranulocytosis was found in the present study. The complete blood counts were not obtained regularly due to the problems of patient's adherence and variations in practice among the physicians. CONCLUSION: Neutropenia is uncommon. No leukopenia and agranulocytosis were found. According to variations of incidence reports among different studies, the monitoring of white blood count should be continued.

Neutropenia, agranulocytosis and dipyrone

CONTEXTO: Neutropenia e agranulocitose podem ser definidas como contagem de granulócitos inferior a 1.500/mm3 e 500/mm3, respectivamente. Agranulocitose é uma doença séria e rara, freqüentemente causada por medicações. A letalidade é de aproximadamente 10%. As manifestações clínicas mais comuns são infecções como tonsilite, faringite, estomatite e pneumonia. A dipirona é uma das medicações sabidamente associadas a agranulocitose. Entretanto, a intensidade desta associação tem sido motivo de muita controvérsia. Adicionalmente, analgésicos e antipiréticos alternativos não são livres de efeitos adversos graves. CONCLUSÕES: Desta forma, é necessário estabelecer a incidência da agranulocitose na América Latina e o papel da dipirona. Com o objetivo de responder estas questões, está em andamento o LATIN, um estudo caso-controle, multicêntrico, internacional.