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A Case of Adalimumab-Associated Pancytopenia – GA ACP 2020

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This is a clinical vignette poster presentation for the GA ACP 2020 annual conference. Thank you for listening!

My name is upashina chandra and i’m a fourth year medical student at the medical college of georgia today i’ll be presenting a case of reversible adalimumab-associated pancytopenia to begin with adelimumab is an anti-tnf alpha biological agent and it’s effective in the management of inflammatory diseases such as rheumatoid arthritis a rare side effect of this

Medication includes bone marrow suppression that leads to cytopenias although this has been reported on only a very few instances this patient that i’ll be presenting is a 54 year old caucasian female with a past medical history of crohn’s disease and rheumatoid arthritis in addition to several other chronic conditions and she was admitted for some severe headaches

And intractable nausea and vomiting at the time of admission she had been on adolume up therapy for her crohn’s and rheumatoid arthritis for about eight months with her last injection two weeks prior to admission she had a known history of borderline low platelet counts typically around a hundred thousand however her labs were notable for pan cytopenia so she

Had low hemoglobin of 10.6 a low white count of 1.6 low platelets at 46 and an anc or absolute neutrophil count of 0.2 however she was pretty asymptomatic from a hematologic standpoint with no bleeding or infection she underwent diagnostic testing to work up her pancytopenia including a peripheral blood smear which was only notable for a nisopoicilocytosis

Or variability in her red blood cell shape and size and um she also underwent infectious workup and metabologi metabolic and endocrine labs to rule out a secondary cause of her pancytopenia including iron studies folate and b12 thyroid function testing and hiv testing and hepatitis testing and all of these were all unremarkable we also tested her for paroxysmal

Nocturnal hemoglobinuria which is a rare cause of pancytopenia this was normal as well and so this brought us to doing a bone marrow biopsy as well as obtaining aspirate which is shown on the images here her bone marrow aspirate smears are the top part of my images and overall this was pretty unsuggestive of a hematologic malignancy if you look at the pictures the

Only real abnormality here are just an increased number of red blood cell precursors and has some noticeable dys erythropoiesis and then her bone marrow biopsy is at the bottom here um you can see that it’s slightly hypercellular but it’s adequate and overall unremarkable for a hematologic malignancy such as leukemia again here you can only really see abnormalities

In the red cells and platelet lines but we also had some evidence of mild reticulin fibrosis which prompted us to do some testing for myelodysplastic syndrome including a karyotype and fish and this was totally within normal limits as well so overall we just decided to hold her atalumumab for three weeks and we followed up with her in our outpatient clinic and a

Cbc obtained at that time demonstrated a resolution of pancytopenia with results that you can see down here in the bottom left corner of my poster so overall this case illustrates pancytopenia in a patient with crohn’s disease and rheumatoid arthritis that resolved in response to discontinuation of her adeline moment therapy and this is one of few reported cases

Of this occurring why is this important so if undetected pan psychopenia can actually leave a patient vulnerable to potentially life-threatening bleeding and infection autoimmune diseases such as rheumatoid arthritis or lupus among many other ideologies are known to cause dysfunction in bone marrow and mild marrow atypia in the setting of cytopenias this marrow

Atypia may actually result in an inappropriate diagnosis of my loaded plastic syndrome when really hurt their pancytopenia may have just been a byproduct of their medication for their autoimmune disease so in conclusion this case highlights the potential need for monitoring cell counts in patients who are on adalimumab therapy in order to avoid missing the rare

But very serious complication of pancytopenia furthermore pathologists and clinicians alike should be aware of the potential of cytopenias occurring due to this medication in order to avoid misdiagnosing mileage’s plastic syndrome among other entities to ensure more accurate and higher quality of patient care my references that i used are at the bottom right

Hand of my poster and i thank you very much for your attention and time

Transcribed from video
A Case of Adalimumab-Associated Pancytopenia – GA ACP 2020 By Upasana Chandra