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.