Pure red cell aplasia after 13 years of sodium valproate, and bone marrow suppression after 17 years of carbamazepine

Abstract

A 38-year-old woman presented with acute hematological toxicity from her anticonvulsants, even though she had been taking them for many years

Figure 1. Patient's Clinical Course, Complete Blood Count, and Reticulocyte Count

The x-axis shows specific dates. In 1985, prior to starting anticonvulsants, the only abnormality was an MCV of 106 fl. On admission (a), in 2001, the only abnormality was an increased MCV of 119 fl. During the second week of admission (b), her WBC, then her platelet count, dropped to their lowest levels, while her Hb showed a gradual decline. Bone marrow biopsy showed suppression of all marrow elements. After stopping carbamazepine, there was a brisk recovery of her WBC and platelet counts. Six weeks later (c), in February 2002, her Hb had dropped to 31 g/l, and she was given a transfusion of packed cells. Eight weeks later (d), in April 2002, despite erythropoietin and steroid therapy, her Hb dropped to 53 g/l and she received another transfusion. At this time, the sodium valproate was stopped. The reticulocyte count had remained abnormally low throughout this period (a–d), and it was only after stopping the valproate that the reticulocyte count and Hb started to rise. Her MCV dropped after the first transfusion and did not rise again until there was a brisk reticulocyte response. ANC, absolute neutrophil count; retic, reticulocytes; Plat(s), platelets.

Figure 2. Bone Marrow Biopsy on Admission, Showing Predominantly Hypocellular Bone Marrow