Post-transfusion purpura (PTP) is a rare disease characterized by life-threatening thrombocytopenia after transfusion of any platelet-containing blood products, such as platelets(PLT) or packed red blood cells (PRBCs). We report an interesting case of PTP in a young lady after receiving multiple blood products. CASE PRESENTATION:A 36-year-old female with a past medical history of diabetes mellitus and left-sided below-knee amputation (BKA) was admitted to the Intensive Care Unit (ICU) for emphysematous osteomyelitis with intraosseous gas in the calcaneus, cuboid, and fifth metatarsal base of the right lower extremity. She underwent right-sided BKA, requiring multiple PRBC transfusions due to a combination of blood loss during surgery and chronic anemia. The initial platelet count was normal at 329,000/uL. Five days after the PRBC transfusion, it trended down to 17,000/uL and there was concurrent development of a purpuric rash over both arms. Bloodwork was notable for elevated prothrombin time and activated partial thromboplastin time. Hemolysis workup and Coombs test were negative. Fibrinogen was elevated, ruling out disseminated intravascular coagulation. PTP was suspected based on the clinical presentation and exclusion of other etiologies. Anti-human platelet antigen-1a (HPA-1a) antibodies were obtained. Empiric treatment with intravenous immunoglobulin (IVIG) and steroids was promptly initiated. Platelet count improved to 157,000/uL after four doses of IVIG. The patient tested positive for HPA-1a. However, due to the urgent need for treatment, the test sample for the anti-platelet antibodies was drawn after the initiation of IVIG. The development of thrombocytopenia in the classic time frame with the characteristic rash and improvement after receiving IVIG make PTP the most likely diagnosis. She was recommended to receive only washed PRBCs in the future to prevent a recurrence. DISCUSSION: PTP is a rare, underdiagnosed, and potentially fatal reaction, with the development of severe thrombocytopenia 2-14 days after transfusion of platelet-containing blood products. It is considered to be caused by alloimmunization against platelet antigens, with HPA-1a being the most common antibody1. Some cases of HPA-1b mediated PTP have been reported as well2. Diagnosis is often subtle and challenging, therefore a strong clinical suspicion is needed. A history of blood product transfusion a few days before the development of thrombocytopenia should make the physician think about the possibility of PTP. Treatment includes IVIG, steroids, or plasmapheresis3, and initiation of treatment should not wait for diagnostic confirmation.CONCLUSIONS: Clinicians should have high clinical suspicion for PTP in patients with acute, severe thrombocytopenia which develops after blood transfusions, and treatment should be initiated early to favorably alter the course of the disease.
What is known and objective Vancomycin, an antibiotic commonly used to treat MRSA infections, can be nephrotoxic. Administering vancomycin requires close monitoring of serum vancomycin levels and appropriate dosing based on patients’ renal function, underlying infection type and serum concentration levels. This article discusses the results and implications of a pharmacist‐driven vancomycin monitoring initiative, which was implemented at Mercy Catholic Medical Center's Philadelphia Campus (MPC) in July 2016. Methods MPC pharmacists were trained on how to give appropriate vancomycin dosing recommendations based on patients’ vancomycin trough levels, renal function and underlying infection. This retrospective observational study consisted of patients who presented to MPC and were administered vancomycin over a 3‐month period in 2015 for pre‐implementation cohort and over a 3‐month period in 2018 for post‐implementation cohort. Patients with age ≥18 and receiving vancomycin for a minimum of 48 hours were included, whereas ESRD patients were excluded. Primary goal evaluated whether the incidence of AKI decreased with the pharmacist‐driven initiative. Secondary goal assessed whether vancomycin level monitoring and achievement of goal serum levels improved with the initiative. Results and discussion A total of 214 patients were included in the final data analysis, with 110 patients in the pre‐implementation cohort and 104 patients in the post‐implementation cohort. Although not statistically significant, a higher incidence of AKI was observed in the post‐implementation cohort. However, compared to pre‐implementation cohort, post‐implementation group had higher percentage of patients with underlying comorbidities (such as CKD), higher number of cases of severe sepsis and septic shock, and greater number of patients with concomitant exposure to CT contrast and piperacillin‐tazobactam—all of which were confounding factors that likely increased the AKI incidence in post‐implementation cohort. With the initiative, there was a significant increase in the number of patients with appropriate vancomycin trough level monitoring (27.3% vs 55.8%, p value < 0.001) in the post‐implementation cohort and a decrease in the number of patients with no trough level monitoring (30% vs. 7.6%, p value < 0.001). What is new and conclusion Pharmacist‐driven vancomycin monitoring significantly improved the monitoring compliance of vancomycin trough levels. In patients who developed AKI during their hospital course, pharmacist interventions improved the total percentage of patients attaining desired trough goals and helped reduce further renal insult from supratherapeutic vancomycin level. Incorporation of AUC‐guided dosing and monitoring has the potential to further optimize vancomycin efficacy and safety.
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