Linezolid-Induced Pure Red Cell Aplasia: A Case Report

Figures & data

Figure 1 Bone marrow smear showed (A) Actively hypercellular marrow with reduced erythropoiesis; Wright-Giemsa Stain, magnification 100x; (B) Vacuolated pronormoblasts; Wright-Giemsa Stain, magnification 400x.

Figure 2 FDG-PET-CT image showing abnormal 18F-flurodeoxyglucose uptake in and around the popliteal artery stent region, suggestive of an active infective. There is possible abscess formation around the left stent.

Figure 3 Hemoglobin and platelet variation detected by complete blood count monitor. (D1 is the first day of first-time LZD-treatment). Multiple antimicrobials were given to the patient before and after LZD therapy was initiated. Blue bars show periods of administration of antibiotics.

Abbreviations: *, Cefaclor; VCM, Vancomycin; LEV, Levofloxacin; RIF, Rifampicin; TEC, Teicoplanin; MIN, Minocycline; MXF, Moxifloxacin; DAP, Daptomycin; MEM, Meropenem; VCZ, Voriconazole.

Table 1 Previous Reports and Our Case of Linezolid-Induced PRCA

Report	Age, Gender	Medical Comorbidities	Underlying Disease	Infecting Organism	Anemia Onset (Length of LZD Treatment)	Change in WBC (*10^9/L)	Change in Platelet (*10^9/L)	Change in HB Level (g/dL)	Change in Retic Count or Percent	Change in Retic Count (*10^12/L)	Bone Marrow Findings
Green et al^Citation4	70, M	/	Infection of Gore-Tex graft	MRSA	16W	/	215 to 60	14.3 to 7.0	/ to 0%	/	Erythroid aplasia (myeloid/erythroid ratio=174:1) with vacuolated erythroblasts
	43, W	/	Sinusitis	MRSA	6W	/	399 to 206	14.1 to 12.8	/ to 0%	/	5 days after cessation of LZD, rare vacuolated erythroblasts
	61, W	Type 2 Diabetes	Osteomyelitis	MRSA	2W	/	/	/	1.4% to 0%	/	/
					4W	/	294 to 125	9.9 to 8	4.5% to 0%	/	/
Monson et al^Citation10	52, M	/	Pneumonia	/	8W	13.2 to /	251 to /	14.5 to 5.9	/	/ to 0.003	RBC aplasia, abnormal pronormoblasts with cytoplasmic vacuoles
Waki et al^Citation12	56, M	MDS	Bacteremia after SCT	Staphylococcus epidermidis	15days	/	/	/ to 6.8	/ to 0.30%	/	RBC aplasia (myeloid/erythroid ratio=402:1) with rare vacuolated pronormoblasts
Taketani et al^Citation11	2, M	/	Infective Endocarditis	Streptococcus mitis	4W	/ to normal	/ to normal	8.9 to 6.5	3.4% to <0.1%	/	Decreased erythropoiesis (myeloid/erythroid ratio=16.31:1) with vacuolar degeneration
Hu et al^Citation9	37, M	MDS, 2-year history of HSCT	CNS infection	/	4W	/	/	12.8 to 7.0	/ to 0.23%	/ to 0.005	Hypo-proliferative anaemia with erythroid cells absence
					6W	/	/	11.7 to 7.7	/ to 0.21%	/ to 0.005	On 52nd of LZD treatment, obvious decrease of erythroid cells
Luo et al^Citation13	83, M	/	Pleural empyema	MRSA	8W	11.8 to normal	177 to normal	10.2 to 5.7	/ to 0.36%	/ to 0.008	Hypoproliferative anemia with markedly decreased erythroid cells. Rare vacuolated pronormoblasts were present
Yang et al (this report)	68, W	Hypertension, carrier of hepatitis B virus, history of right breast cancer, and lumbar spine infection	Vascular stent infection	MRSH	23days	13.9 to 6.1	273 to 66	12.3 to 10.1	/	/	/
					8W	11.3 to 6.5	325 to 179	9.5 to 4.1	/ to 0.2%	/ to 0.003	Markedly decreased erythropoiesis(myeloid/erythroid ratio=68:1) with vacuolated pronormoblasts
					12days	13.6 to 6.5	359 to 236	9.6 to 7.3	/	/	/

Abbreviations: LZD, linezolid; WBC, white blood cell count; HB, hemoglobin; retic, reticulocyte; MRSA, methicillin-resistant Staphylococcus aureus; SCT, hematopoietic stem cell transplantation; HSCT, hematologic stem cell transplantation; CNS, central nervous system; EPO, erythropoietin; RBC, red blood cells.

Table 2 Treatment and Recovery Time of Anemia for LZD-Induced PRCA

Report	Age, Gender	Medical Comorbidities	Underlying Disease	Infecting Organism	Other Treatment	Recovery (Length of Cessation of LZD Treatment)	Change in WBC (*10^9/L)	Change in Platelet (*10^9/L)	Change in HB Level(g/dL)	Change in Retic Count or Percent (%)	Change in Retic Count (*10^12/L)
Green et al^Citation4	70, M	/	Infection of Gore-Tex graft	MRSA	/	10days	/	60 to normal	7.0 to normal	0% to 5.8%	/
	46, W	/	Sinusitis	MRSA	/	1w	/	208 to normal	12.8 to normal	0% to 2.4%	/
	61, W	Type 2 Diabetes	Osteomyelitis	MRSA	/	2w	/	/	/	/	/
					/	/	/	125 to normal	8.0 to normal	/	/
Monson et al^Citation10	52, M	/	Pneumonia	/	/	10days	/	/	6.1 to 8.6	/	0.007 to 0.363
Waki et al^Citation12	56, M	MDS	Bacteremia after SCT	Staphylococcus epidermidis	/	12days	/	/	6.8 to 8.6	0.3% to 2.80%	/
Taketani et al^Citation11	2, M	/	Infective Endocarditis	Streptococcus mitis	Iron and B multivitamins, including vitamin B1, B2, B6, B12, and folic acid. Single RBC transfusion	19days	/	/	6.5 to 9.6	/	/
Hu et al^Citation9	37, M	MDS, 2-year history of HSCT	CNS infection	/	EPO, RBC transfusions	24days	/	/	7.0 to 11.7	/
					EPO, RBC transfusions, halve LZD dosage	16w (halve LZD dosage)+2w(cessation of LZD)	/	/	5.5(Nadir) to 8.2(7w after halve LZD dosage) to 11(2w after cessation of LZD)	0.21% to / to 1.65%(2w after cessation of LZD)	0.005 to / to 0.05(2w after cessation of LZD)
Luo et al^Citation13	83, M	/	Pleural empyema	MRSA	RBC transfusions	2w	/	/	5.7 to 8.4	0.36% to 4.80%	0.008 to 0.436
Yang et al(this report)	68, W	Hypertension, carrier of hepatitis B virus, history of right breast cancer, and lumbar spine infection	Vascular stent infection	MRSH	/	12days	6.1 to 11.3	66 to 358	10.1 to 9.5	/	/
					EPO, RBC transfusions	12days	6.5 to 13.6	179 to 330	4.1 to 9.6	0.2% to 5.1%	0.003 to 0.144
					EPO, RBC transfusions	12days	6.5 to 7.5	236 to 321	6.7 to 11.9	/	/

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