Linezolid-Induced Pure Red Cell Aplasia: A Case Report

Abstract

Linezolid (LZD) has been widely used for treating the infections of multidrug-resistant gram-positive organisms. As we know, anemias induced by Linezolid (LZD) are common. However, LZD-induced pure red cell aplasia (PRCA) is very rare. In this paper, we report on a 68-year-old woman with intravascular stent infection who developed PRCA after treatment with LZD. The patient presented to our hospital with a 6-month history of fever after stent implantation for aneurysms in both lower limbs. Bone culture grew methicillin-resistant Staphylococcus hemolyticus (MRSH). She received LZD after developing adverse reactions to initial antibiotics. Although her infective symptoms were improved by LZD, progressive thrombocytopenia was observed 23 days after LZD therapy. Her platelets declined to 66*10⁹/L and hemoglobin level was 10.1 g/dL. Thrombocytopenia recovered 12 days after cessation of LZD. LZD was administered again due to recovered fever. 57 days after LZD administration, her hemoglobin level was 4.1 g/dL and reticulocytes were 0.2%. Bone marrow smear revealed active granulocyte proliferation and markedly decreased erythropoiesis with vacuolar degeneration. 12 days after cessation of LZD, her hemoglobin and reticulocyte levels rose to 9.6 g/dL and 5.1%, respectively. LZD was used for the third time as fever and inflammatory markers progressively increased, but Hb was reduced to 6.7g/dL 15 days after LZD therapy. 12 days after cessation of LZD, the hemoglobin level rose to 11.9 g/dL. In summary, we suggest complete blood count and reticulocyte count should be monitored to detect bone marrow suppression during long-term LZD therapy, especially in patients aged over 58 and/or with pre-existing anemia, chronic infections, and renal insufficiency.

Keywords: adverse reactions; anemia; linezolid; myelosuppression; pure red cell aplastic anemia.

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.