Thrombocytopenia of Unusual Etiology in the Intensive Care Unit

Abstract

Thrombocytopenia is a relatively common laboratory finding in the intensive care unit (ICU) that may be caused by a variety of triggers. Vancomycin may lead to the production of antibodies that could precipitate a severe drop in platelet count. The objective of the current report was to describe the development of severe thrombocytopenia during the infectious work-up of a critical care patient, where an association between vancomycin and thrombocytopenia was unexpectedly identified. The current report describes the case of a 64-year-old female who presented with dyspnea on exertion and resting hypoxia to an outside facility and was initially treated for a chronic obstructive pulmonary disease exacerbation. She was then transferred to Mayo Clinic for further care. After 72 h, she acutely decompensated requiring increasing oxygen support with a questionable infiltrate on chest imaging and was transferred to the ICU. She was placed on non-invasive ventilation with poor gas exchange and ultimately required intubation. Antibiotics were expanded to include vancomycin. Within 72 h of antibiotic initiation, her platelet count decreased from 379 × 10 9 /L to 7 × 10 9 /L. After a negative heparin-induced thrombocytopenia panel and serotonin assay, the antibiotics were discontinued and her platelet count subsequently increased. Despite the fact that heparin is a common culprit of drug-induced thrombocytopenia, the patient had no evidence of this association. She received three doses of vancomycin prior to the recognition of the association between this medication and thrombocytopenia. Her platelet count only started to recover once vancomycin was discontinued. In conclusion, vancomycin is commonly administered in the critical care setting and may lead to the development of thrombocytopenia. Vancomycin-induced thrombocytopenia is caused by antibodies that may remain for years after last exposure. Appreciation of the association between vancomycin and thrombocytopenia may ultimately lead to improved patient outcomes.

Rapid-Onset Vancomycin-Induced Thrombocytopenia With Reexposure

“…Whereas there have been 30 documented cases of VIT, thrombocytopenia occurred within 24 hours of vancomycin administration in only 6 cases, including ours (Table 1). [3][4][5][6][7] Previous exposure to vancomycin was noted in 5/6 of these cases and prior evidence of VIT was noted in 3/6 cases, so drug sensitization followed by reexposure appears to be a risk factor for rapid-onset thrombocytopenia. In 1 case of severe thrombocytopenia to 3000/mm 3 aware that thrombocytopenia is a rare but potentially serious side effect of vancomycin that may occur rapidly (within 24 hours) with previous sensitization to the drug.…”