Hypersensitivity reaction and acute immune-mediated thrombocytopenia from oxaliplatin: two case reports and a review of the literature

Abstract

Background: Oxaliplatin is a platinum compound used in the treatment of gastrointestinal malignancies, including colorectal cancer. The incidence of hypersensitivity reaction in patients receiving oxaliplatin is approximately 15%, with severe reaction (grade 3 and 4) occurring in 2% of patients.

Case presentation: We report two patients with metastatic colorectal cancer who developed de novo hypersensitivity reaction and acute thrombocytopenia after oxaliplatin infusion. Both patients had oxaliplatin treatment several years before and exhibited hypersensitivity on the third dose of oxaliplatin in recent treatment. Oxaliplatin was discontinued when clinical reaction was identified. Both patients were confirmed to have strong oxaliplatin-induced IgG platelet-reactive antibodies. Both patients' thrombocytopenia resolved within two weeks after discontinuation of oxaliplatin. One patient had disease stabilization lasting for three months without chemotherapy. Both patients subsequently received other chemotherapeutic agents without evidence of hypersensitivity reaction or immune-mediated thrombocytopenia.

Conclusion: We recommend vigilant monitoring of complete blood count and signs and symptoms of bleeding after the occurrence of oxaliplatin-induced hypersensitivity to avoid serious complications of immune-mediated thrombocytopenia.

Figure 1

Photographs form patient one taken 24 hours after oxaliplatin infusion. A. Intense epistaxis with placement of nasal packing, and tongue-hematoma formation. B. Upper extremity petechiae, bruises and accumulation of blood in the colostomy.

Figure 2

Peripheral blood smears. A. Patient one: markedly decreased platelets without significant schistocytosis. (Wright's stain, 1,000×) B. Patient two: moderate decline in platelets. (Wright's stain, 1,000×)

Figure 3

Plots displaying the trend of platelet counts. A. Patient one: the steep platelet decline occurring 24 hours after completion of oxaliplatin infusion, with concurrent bleeding diathesis. Two units of apheresis platelets were provided. B: Patient two: moderate decrease in platelet count without evidence of bleeding. Platelet drop was not as drastic as patient one due to discontinuation of the rest of oxaliplatin treatment.

Figure 4

Detection of oxaliplatin-dependent platelet antibodies. The assay was performed by flow cytometry in patient one (A) and patient two (B). Both patients had IgG antibodies that reacted strongly with normal platelets in the presence of 0.1 mg/ml oxaliplatin, but not in the absence of drug. No reaction was obtained with normal serum in the presence of drug.