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A rare complication of treatment following coronary stenting
U
Nandy*, GI Varughese**, N Iqbal***, AD Vellore****, MN Payne*****
*Department of Dermatology, Ninewells Hospital, Dundee DD2 1UX, U.K.
**Department of Endocrinology, Princess Royal Hospital, Telford TF1 6TF, U.K.
*** Registrar in General Practice, Leicester Deanery, Leicestershire, U.K.
****Department of Chest Medicine, Heartlands Hospital, Birmingham B6 5SS, U.K.
*****Department of Cardiology, Manor Hospital, Walsall WS2 9PS, U.K.
Address
for Correspondence:
Dr. U. Nandy
35 Lister Place
Ninewells Hospital
Dundee DD2 1UX
Tel: 01382 669998 Fax: 01922 656449
E-mail: utpalnandy@hotmail.com
Abstract:
A 57 year old man was admitted with an extensive purpuric rash and bleeding gums within a day after coronary angioplasty. He had been treated with three anti-platelet agents which included aspirin, clopidogrel and abciximab. Though the risk of thrombocytopaenia is well described, the actual life threatening consequences of low platelet counts are less commonly perceived.
Keywords: Clopidogrel; Abciximab; Thromboctopaenia
Introduction:
Antiplatelet agents are being increasingly used for the treatment of coronary disease. While modern medications are effective and beneficial, life threatening side effects can occur rarely and has to be managed aggressively.
Case Report:
A 57 year old was admitted 24 hours after he had a coronary angioplasty, with bleeding gums and multiple purpuric spots on his trunk limbs and abdomen [see Images 1-5]. He was on treatment with Clopidogrel 75mg, Aspirin 75mg and had also received abciximab [glycoprotein II b /III a inhibitor]. His other medications included Amlodipine, Atorvastatin and Valsartan.The platelet count was 2 X 109 /l [Normal 250-450 X 109 /l], and all other blood tests including Hb, White cell count, Liver function tests, Renal functions, Inflammatory markers and Clotting parameters were normal. He was treated with platelets transfusions and intravenous immunoglobulins. The platelet count gradually improved to 212 X 109 /l within a span of six days, and he was allowed home.
Images
Image 1: Multiple petechial areas around the cubital fossa and forearm
Image 2: Bruising below the popliteal fossa
Image 3: Purpuric areas on the tongue
Image 4: Multiple haemorrhagic areas on the shins
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Image 5: Bruise marks and petechiae around the ankle
Discussion:
Clopidogrel in combination with abciximab has been shown to have a higher incidence of significant thrombocytopaenia than clopidogrel and other medications like ticlopidine [1]. Clopidogrel has been also reported to cause thrombotic thrombocytopaenic purpura [2] more often, than just thromboctopaenia alone [3]. Heparin, Aspirin, Clopidogrel and Abciximab in a variety of combinations are used in managing patients with coronary disease. There has been reports of acute profound thrombocytopaenia in the setting of coronary angioplasty and the dilemmas in managing these patients that may arise as no test can definitively identify the offending drug, and stopping these drugs can affect the outcome of the coronary event including stent thrombosis [4]. Clopidogrel is a recently developed thrombocyte inhibitor with fewer side effects, and is widely used in clinical practice, the occurrence of hematological and dermal side effects should be considered [5]. Studies have shown that amongst the various platelet glycoprotein II b /III a inhibitors that are available, abciximab has been found to have a higher incidence of thrombocytopaenia though the overall complication rates of bleeding are similar [6].
Abciximab, eptifibatide, and tirofiban are the three drugs commonly used to block platelet aggregation by binding glycoprotein IIb/IIIa. Results from large therapeutic trials have shown that all three agents induce thrombocytopenia in approximately 1% to 5% of cardiac patients [7]. Thrombocytopenia is typically rapid in onset and antibody mediated. Studies have shown that in vitro evidence suggests abciximab-induced thrombocytopenia is associated with antibodies directed to murine sequences within the chimeric anti-IIb/IIIa molecule [7]. In addition, abciximab, eptifibatide, and tirofiban also function as mixed agonist-antagonists in vivo, inducing neoepitopes within the glycoprotein IIb/IIIa receptor that may react with pre-existing or induced antibodies [7]. Screening for the development of these antibodies may reduce the incidence of thrombocytopenia associated with these agents, but it may limit their chronic usage.
References:
[1] Dillon WC, Eckert GJ, Dillon JC et al. Incidence of thrombocytopenia following coronary stent placement using abciximab plus clopidogrel or ticlopidine. Catheter Cardiovasc Interv 2000 Aug;50(4):426-30.
[2] Bennett CL, Connors JM, Carwile JM et al. Thrombotic thrombocytopenic purpura associated with clopidogrel. N Engl J Med 2000 Jun 15;342(24):1773-7.
[3] Briguori C, Manganelli F, Picardi M et al. Thrombocytopenia and purpura-like lesions associated with clopidogrel. Ital Heart J 2001 Dec;2(12):935-7.
[4] Makoni SN. Acute profound thrombocytopenia following angioplasty: the dilemma in the management and a review of the literature. Heart 2001 Dec;86(6):E18.
[5] Reichenberger F, Wirtz H, Paschke R. Clopidogrel and side effects. Cardiology 2001;96(1):51-2.
[6] Suleiman M, Gruberg L, Hammerman H et al. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, eptifibatide and abciximab: outcomes, complications and thrombocytopenia during percutaneous coronary intervention. J Invasive Cardiol 2003 Jun;15(6):319-23.
[7] Abrams CS, Cines DB. Thrombocytopenia After Treatment with Platelet Glycoprotein IIb/IIIa Inhibitors. Curr Hematol Rep 2004 Mar;3(2):143-7.
Learning points:
· Clinicians working in specialities other than cardiology or haematology should have a high index of suspicion in this group of patients who may present with minimal bleeding diatheses, in order to avoid life threatening complications.
· Patients should be advised about the potential side effects of these medications and the importance of immediately reporting to hospital has to be
emphasised.
· Thrombocytopaenia associated with these antiplatelet agents are well described, but less well recognised and perceived in clinical practice. |
| This
is a peer reviewed article. Accepted for publication on May
10,2004
Cite
as:
Nandy U,Varughese GI,Iqbal N,Vellore AD,Payne MD
A rare complication of treatment following coronary stenting
Calicut
Medical Journal 2004;2(3):e2
URL: http://www.calicutmedicaljournal.org/2004/2/3/e2
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