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2014 Pennsylvania Chapter Eastern Region Abstract Winner

2014 Pennsylvania Chapter Eastern Region Abstract Winner

Medical Students
First Place

An Unusual Case of Spironolactone Induced Neutropenia

Author: Jennifer O'Loughlin Langstengel, TCMC
Co-Authors: Blake Bloxham, DO, MHA, Benjamin Hohmuth, MD, MPH
Department of Hospital Medicine, Geisinger Medical Center

Neutropenia, characterized by an isolated decrease in granulocytes with otherwise intact cell lines, is an alarming condition. A 43 year old woman presented to the emergency department for evaluation of near syncope, fever, left upper quadrant abdominal pain, and malaise for the past week. Social history revealed that the patient works as a nurse and lives on a livestock farm. She had no significant past medical or surgical history, and was taking no medications, including over the counter or herbals. Prior to admission, she was seen by another practitioner for hirsutism and was prescribed spironolactone 50mg once daily. Six days prior to admission, she was seen by her family doctor for near syncope and instructed to stop the spironolactone. Physical exam noted no rash, hepatosplenomegaly, adenopathy, or thrush. She complained of tenderness to palpation in the left upper quadrant. CBC with differential revealed: a hemoglobin level of 13.2 g/dL, platelet count of 245,000, and an absolute neutrophil count (ANC) of 69. No other abnormalities were noted on her differential. Broad spectrum antibiotics were initiated with Cefepime and Vancomycin. Blood and urine cultures collected prior to antibiotics were negative. Further testing for viral and tick-borne illnesses was negative. Peripheral blood flow cytometry revealed a relative reactive lymphocytosis. On hospital day two, ANC was 38; on day three, her ANC had increased to 626; and on the day of discharge ANC was 1293. Ten days after presentation to the emergency department her ANC had returned to normal limits at 5375. Spironolactone is a commonly used medication linked to neutropenia in patients with significant co-morbidities. Although there is limited literature on this phenomenon, most reports have been in patients with renal or liver dysfunction on diuretic therapy. However, this patient possessed no co-morbidities and the severity of the neutropenia was unusual.