2. CASE REPORT
A 79-year-old male patient with a 10-year history of chronic obstructive
pulmonary disease (COPD) was admitted to the pneumology department of
our hospital in July 2020 complaining of acute exacerbation of cough,
dyspnea, wheezing. He also had a history of type 2 diabetes mellitus for
10 years, and hypertension for 6 years. He had no history of allergies
reaction for drugs and food. His vitals on admission were temperature
36.5℃, blood pressure 112/82 mm Hg, pulse rate 84 beats/min and
respiratory rate 18 breaths/min. Pulmonary examination revealed a
“barrel-shaped” chest, a few
moist
rales at bilateral lungs. Laboratory examination revealed the white
blood cell count (WBC) of 10.34×109/L, the neutrophils
conut of 9.65×109/L, the platelets count of
150×109/L, the
hemoglobin concentration of 145g/L, the serum C-reactive protein (CRP)
concentration of 0.97 mg/L. A chest computed tomography (CT) scan showed
chronic bronchitis, emphysema and a small amount of infection in
bilateral lungs. The patient was diagnosed with acute exacerbation (AE)
of COPD.
After admission, he was received losartan (100mg orally, once daily),
gliclazide (60mg orally, once daily), doxofylline (0.3g intravenously
guttae, once daily), bromhexine (4mg intravenously guttae, twice daily),
piperacillin-tazobactam (4.5g intravenously guttae, every 8 hours), and
methylprednisolone (40mg intravenously guttae, twice daily). On the
fourth day following admission, the symptoms of cough and shortness of
breath were improved. The repeat laboratory investigations showed WBC
8.3×109/L, neutrophils 7.08×109/L,
platelet 76×109/L, haemoglobin 133g/L. On the eighth
day following admission, the patient’s general condition was good, and
he asked to be discharged from the hospital, which was allowed.
In March 2021, the same patient was re-hospitalized for AECOPD and
pulmonary
infection. Laboratory examination revealed WBC
9.91×109/L, neutrophils 8.76×109/L,
platelets 149×109/L. After admission, his medications
were the same as the previous admission except the
piperacillin-tazobactam (4.5g intravenously guttae, every 8 hours) and
levofloxacin (0.5g intravenously guttae, once daily) were administered
for pulmonary infection. However, on the third day, the repeat
laboratory investigations showed the platelet levels of the patient
rapidly drop to 25×109/L, but others normal. He had no
neurological deficits, purpura or petechiae, mucosal bleeding, or
epistaxis. The condition was considered thrombocytopenia associated with
antibiotics. The severity of thrombocytopenia was assessed as grade 3,
according to the grading criteria for bone marrow
hypocellular.7 Therefore, piperacillin-tazobactam and
levofloxacin were discontinued. The meropenem 1g intravenously every 8
hours was administrated to complete treatment of his pulmonary
infection. The platelet count gradually improved to
96×109/L 9 days after discontinuation of
piperacillin-tazobactam without any other intervention (Figure 1). On
the fourteenth day following admission, the patient was discharged for
the cough and dyspnea improved. Seven days later, the patient was
followed up in the outpatient, and the count of platelet returned to
normal.
In May 2021, the patient was also admitted for AECOPD and pulmonary
infection with an initial platelet count of 184×109/L.
His medications were the same as the previous admission except the
ceforiam 2g intravenously every 12 hours was administered for infection.
The platelet count on the third and the ninth day of admission was
159×109 /L and 155×109 /L,
respectively. On the eleventh day following admission, the patient
reported that the cough and sputum improved, and was discharged.
In August 2021, the patient was re-admitted for AECOPD and pulmonary
infection. Laboratory examination revealed WBC
7.71×109/L, haemoglobin 119g/L,platelets
122×109 /L. The anti-infection regimen was switched to
cefoperazone-sulbactam 4g intravenously every 12 hours. However, the
platelet count fell to 22x109 /L after seven days from
time of administration, and the count of WBC was
5.68×109/L, the hemoglobin was 118g/L. The condition
was also considered thrombocytopenia associated with antibiotics. The
severity of thrombocytopenia was assessed as grade 3, according to the
grading criteria for bone marrow hypocellular.7Therefore, cefoperazone-sulbactam was discontinued. Recombinant Human
Interleukin-11 3 mg was administered subcutaneously once daily. Over the
next 4 days, the platelet count of the patient increased from
40x109 /L to 64x109 /L (Figure 1).
The patient’s symptoms of cough and shortness of breath were relieved
and he was discharged. The platelets count returned to normal level
after two weeks of follow-up. The depiction of the patient’s time course
of thrombocytopenia and exposure to potential antibiotics were presented
in figure 1.