Case 1120 - Female in Her Early 70s with Pancytopenia and Sepsis

Contributed by Katherine Killian, DO and Lirong Qu, MD, PhD

Patient History

A woman in her early 70s presented to the emergency department with fevers and generalized malaise. She had a history of pulmonary embolism on long term anticoagulation with rivaroxaban, irritable bowel syndrome, psoriasis, and myelodysplastic syndrome.  She was seen by her oncologist a week prior and completed one treatment of Gemtuzumab.

In the emergency department, her vitals were significant for a fever of 39.5 °C and hypertension (BP 192/91). CT of the abdomen/pelvis showed colitis in distal colon and rectum, favored to be an infectious or inflammatory etiology. An occult blood stool test was positive.

Labs on admission showed hemoglobin initially 9.5g/dl (12-16 g/dl) and platelets 13,000/μL (150,000/μL to 450,000/μL). Repeat labs showed a drop in hemoglobin to 7.7 g/dl and platelets to 9,000/μL.

Blood cultures were obtained and have returned positive gram-negative rods & gram-positive cocci in chains and sepsis work-up was initiated.

She was transfused with a dose of apheresis platelets and given 1000mg of acetaminophen for high fevers prior to transfusion. The transfusion was stopped 90 minutes after initial start due to rise in temp from 98.5F to 103.1F with chills and dyspnea. Blood pressure went up slightly from 126/69 to 144/66, she remained tachycardic going from 124 to 136bpm.  A transfusion reaction workup was performed.  Blood bank laboratory investigation for hemolysis was negative. The patient had positive DAT (direct antiglobulin test) with anti-IgG in both pre and post transfusion specimens with no increase in strength of reactivity after the transfusion.

Due to the transfusion reaction and she was admitted to the ICU with consults to pulmonary and critical care, hematology/oncology, cardiology and infectious disease.

After admission, she was given three additional platelet transfusions. Despite these transfusions, she remained thrombocytopenic.  The patient was tested for HLA antibody and was found to have 100% calculated PRA (panel reactive antibody). She subsequently received 1 dose of HLA matched platelets with appropriate increment.

Diagnosis and Discussion