Case Report
A 64-year-old male patient was admitted to hospital on April 21st, 2021
(Day 1, hereafter referred as D1) with 3-day-paroxysmal abdominal
cramps, accompanied by diarrhea, nausea as well as vomiting. The
diagnosis was transverse colon perforation on admission, with rectal
mass, septic shock and hypokalemia. An emergency surgery was performed
to repair laparotomy perforation as well as radical treatment of rectal
cancer. After the operation, he was transferred to intensive care unit
(ICU) (D1). The score of the sequential organ failure
assessment9, acute physiology and chronic health
evaluation10, and Richmond agitation-sedation
scale11 was 8, 19 and -2 scores, respectively. For
surviving sepsis, ICU physicians implemented bundle strategies as
antimicrobial therapy (imipenem and cilastatin sodium for injection,
0.5g q6h), fluid resuscitation (20% human albumin, 40g; crystoloid
solution, 3000ml) and sedation therapy (remifentanil, propofol,
midazolam).
During the ICU hospitalization (D1-D9), his blood routine examinations,
body temperature, and procalcitonin are shown in Table 1. On D2,
vancomycin (1g, q12h) was administrated intravenously combined with
imipenem and cilastatin sodium, due to an operative recording showing a
serious fecal contamination in his abdominal cavity. Unexpectedly, his
platelets count (7 × 109/L) severely decreased on D4
(Figure 1). According to the blood routine test (Table 1) and medical
history, we roughly excluded common blood diseases and autoimmune
diseases. Meanwhile, hepatic failure and disseminated intravascular
coagulation (DIC) were put aside. Thus, idiopathic thrombocytopenic
purpura (ITP) was a major concern which might be caused by infection or
medications, etc. After transfusion of platelets (1 U) and blood cells
(2 U) on D4, his platelets count recovered a little (26 ×
109/L). However, it went down again in the morning of
D5 (14 × 109/L). The severe infection, as the first
factor suspected to thrombocytopenia was alleviating at the same moment.
Among all the medication used between D1-D5, vancomycin aroused
suspicion and was discontinued (with its trough concentration being as
11 ug/ml). And a platelet transfusion (1U) was given to prevent
hemorrhage.
In the evening of D5, as the body temperature increased to 38.7℃, the
patient had to re-administered vancomycin. As a result, his platelets
count was reduced from 61 × 109/L to 3 ×
109/L within 8 hours. He had to receive a platelets
(2U) transfusion again in the morning of D6. As drainage fluid culture
suggested only Escherichia Coli (ESBL-) infection, we completely
discontinued vancomycin but kept on imipenem and cilastatin sodium. The
platelets count backed to 135 × 109/L on D7 and never
dropped again since then. He was transferred back to the general ward
after being extubated (D9). On D14, he stopped using antibiotics and was
discharged with a better health condition. According to the Naranjo
adverse reaction evaluation scale (Table 2)12, the
total score was 6, and the relationship between vancomycin and
thrombocytopenia was judged as ”probably”.