6/6/2017. Very Severe Aplastic Anemia During Treatment With Doxycyclin... : American Journal of Therapeutics.
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Letters to the Editor
Very Severe Aplastic Anemia During Treatment With Doxycycline
To the Editor:
CASE REPORT A 42-year-old male presented to the emergency department with 3 weeks history of fatigue and epistaxis. On initial blood work, he was found to have pancytopenia with hemoglobin of 4.7 g/dL, platelet count of 4000, and absolute neutrophil count of 160. He has no significant family history. His medical history was only significant for a rash, which was biopsied 3 months ago and reported to be follicular dermatitis. He was prescribed doxycycline 100 mg twice a day which he reports to be taking for the past 6 weeks. He denies usage of any other over the counter medications. His bone marrow biopsy was reported to be hypocellular (,5% cellularity) with normal morphological features (Figure 1). He was transfused with packed red blood cells and platelets to maintain hemodynamic stability. Paroxysmal nocturnal hemoglobinuria was ruled out using flow cytometry (negative for CD59 and CD55). Workup including HIV, Epstein-Barr virus, Hepatitis B and C, and parvovirus serology are reported to be negative. In congruence with the above-mentioned findings, he was diagnosed with very severe aplastic anemia (vSAA) and treated with immunosuppressive therapy with equine antithymocyte globulin and cyclosporine, and currently, awaiting for allogeneic bone marrow transplant. Because of the temporal relationship between prolonged doxycycline administration and aplastic anemia and the lack of any other explanation, we conclude that this case illustrates a rare but potentially fatal complication of this drug. Aplastic anemia is a remarkably rare but a serious adverse effect of drug therapy such as antimicrobials. We report this as the first case, to the best of our knowledge based on the literature review, of possible doxycycline-induced vSAA. Our patient had history of a rash for which he was taking doxycycline for a few weeks before he presented with pancytopenia. Acquired aplastic anemia is a rare hematological disorder presenting with pancytopenia and a predominantly empty American Journal of Therapeutics (2017) 24(4)
FIGURE 1. Hypocellular bone marrow.
marrow with normal morphological features. It is a fatal disease, and irrespective of the etiology, without treatment, patients usually succumb because of infection and bleeding. Cases have been reported with tetracycline as a causative agent of aplastic anemia.1 We hypothesize doxycycline to be the possible etiology of SAA in this patient. Practitioners need to be aware of this rare but fatal complication of this widely used antibiotic. Prabhsimranjot Singh, MBBS1 Ankur Sinha, MBBS2 Anisha Kamath, MBBS2 Sonali Malhotra, MBBS3 1 Department of Hematology/Oncology Maimonides Medical Center Brooklyn, NY 2 Department of Internal Medicine Maimonides Medical Center, Brooklyn, NY 3 Department of Pediatric Endocrinology Maimonides Medical Center Brooklyn, NY The authors have no conflicts of interest to declare.
REFERENCE 1. Lehrner LM, Cooke JH, Enck RE. Tetracycline-induced aplastic anemia. South Med J. 1979;72:358–361. www.americantherapeutics.com
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