Agranulocytosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Daniel A. Gerber, M.D. [2] Nazia Fuad M.D.

Synonyms and Keywords: Agranulosis, granulocytopenia, neutropenia

Overview

Agranulocytosis is defined as marked reduction in the number of granulocytes (Neutrophils, Basophils, Eosinophils) below an absolute count of 500 cells/pL. It is a rare condition with incidence of 1 to 5 cases per million population per year. Agranulocytosis results in frequent chronic bacterial infections of skin, lung, and throat. Patients can present with sepsis and fever. Among many risk factors, medications, combination therapy with ACE inhibitors and interferon, cytotoxic chemotherapy, hematologic malignancies, and autoimmune disorders are the more common. On the basis of etiology agranulocytosis can be classified as congenital and acquired. Common causes of acquired agranulocytosis include medications like clozapine, sulfasalazine, and thioamide, infections, nutritional deficiencies, myelodysplasia, collagen vascular diseases, and white cell aplasia. Agranulocytosis needs to be differentiated from bacterial sepsis, aplastic anemia, acute myeloid leukemia, acute lymphoblastic leukemia, cytomegalovirus, folic acid deficiency, and hodgkin lymphoma. The negative prognostic factors in the course of agranulocytosis are age > 65, septic shock, bacteremia, systemic infections, renal, cardiac and respiratory diseases.The mainstay of treatment of agranulocytosis is medical therapy, including, discontinuation of offending agent, treating infections with broad spectrum antibiotics, and using granulocyte-colony stimulating factor.

Historical Perspective

  • Agranulocytosis was first noted around the beginning of the 20th century on review of blood cell differentials described in patients with lupus, other autoimmune disorders, and with various drug toxicities.[1]

Classification

Agranulocytosis can be classified as congenital or acquired. Each class can be classified to further subgroups as follows:

Congenital
Acquired

Pathophysiology

Agranulocytosis develops as a result of the following mechanisms:[2]

Causes

Agranulocytosis can be congenital or acquired. Common causes of acquired agranulocytosis include:[4][5]

Differentiating Agranulocytosis from Other Diseases

Consider the following differential when evaluating a patient with agranulocytosis:

Epidemiology and Demographics

  • Agranulocytosis is an extremely rare condition.
  • The overall incidence rate is 7.2 per million per year.[6]
  • It can occur in all races and any age group.
  • The acquired type of agranulocytosis is more common in older individuals. While inherited type is commonly seen in children.
  • The risk of agranulocytosis is seen higher in women.[7]

Risk Factors

Risk factors for agranulocytosis include:

Screening

There are no routine screening recommendations for agranulocytosis. It is typically identified incidentally on routine blood work or while monitoring after cytotoxic therapy.[13]

Natural History, Complications, and Prognosis

Natural History

Complications

The major complications of agranulocytosis are as follows:[14]

Prognosis

The negative prognostic factors for agranulocytosis are:[15]

Diagnosis

Diagnostic Study of Choice

The diagnosis of agranulocytosis is based on the laboratory finding when the number of granulocytes (Neutrophils, Basophils, Eosinophils) is below an absolute count of 500 cells/pL.

History and Symptoms

History of patients with agranulocytosis should focus on any history of:[16]

Common symptoms include:[16]

Physical Examination

Common signs of agranulocytosis may include:

Laboratory Findings

The following tests should be performed after careful medication history:

Some patients may need:

Electrocardiogram

There are no ECG findings associated with agranulocytosis.

X-ray

There are no x-ray findings associated with agranulocytosis. However, an x-ray may be helpful in the diagnosis of underlying cause or complications of agranulocytosis.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with agranulocytosis.

CT scan

There are no CT scan findings associated with agranulocytosis. However, a CT scan may be helpful in the diagnosis of underlying cause or complications of agranulocytosis.

MRI

There are no MRI findings associated with agranulocytosis. However, a MRI may be helpful in the diagnosis of underlying cause or complications of agranulocytosis.

Other Imaging Findings

There are no other imaging findings associated with agranulocytosis.

Other Diagnostic Studies

There are no other diagnostic studies associated with agranulocytosis.

Treatment

Medical Therapy

  • Discontinuation of the offending agent
    • Identifying and removing the offending agents
    • It takes about 1-3 weeks for neutropenia to resolve after stopping the offending drug.
  • Bone marrow transplant
    • When other treatments do not work, bone marrow transplant is an option.
    • It is more successful in patients aged <40 years old in good health.

Surgery

There are no surgical treatments for agranulocytosis. However, in patients with neutropenic fever, surgical intervention may be necessary depending on the source of infection.[13]

Primary Prevention

Primary prevention of agranulocytosis is dependent upon:

Secondary Prevention

Effective measures for the secondary prevention of agranulocytosis include early detection and treatment of underlying conditions.

See also

References

  1. Dameshek W. (1944). "Leukopenia and Agranulocytosis.". Oxford University Press. 1: 841–52. 
  2. Pontikoglou, Charalampos; Papadaki, Helen A. (2010). "Idiosyncratic Drug-Induced Agranulocytosis: The Paradigm of Deferiprone". Hemoglobin. 34 (3): 291–304. ISSN 0363-0269. doi:10.3109/03630269.2010.484791. 
  3. Uetrecht, Jack; Zahid, Nasir; Tehim, Ashik; Mim Fu, J; Rakhit, Suman (1997). "Structural features associated with reactive metabolite formation in clozapine analogues". Chemico-Biological Interactions. 104 (2-3): 117–129. ISSN 0009-2797. doi:10.1016/S0009-2797(97)00017-3. 
  4. Andersohn F, Konzen C, Garbe E. (2007). "Systematic review: agranulocytosis induced by nonchemotherapy drugs.". Ann Internal Med. 146(9): 657–65. 
  5. Andersohn, Frank; Konzen, Christine; Garbe, Edeltraut (2007). "Systematic Review: Agranulocytosis Induced by Nonchemotherapy Drugs". Annals of Internal Medicine. 146 (9): 657. ISSN 0003-4819. doi:10.7326/0003-4819-146-9-200705010-00009. 
  6. Strom, Brian L. (1992). "Descriptive Epidemiology of Agranulocytosis". Archives of Internal Medicine. 152 (7): 1475. ISSN 0003-9926. doi:10.1001/archinte.1992.00400190095018. 
  7. Alvir, Jose Ma. J.; Lieberman, Jeffrey A.; Safferman, Allan Z.; Schwimmer, Jeffrey L.; Schaaf, John A. (1993). "Clozapine-Induced Agranulocytosis -- Incidence and Risk Factors in the United States". New England Journal of Medicine. 329 (3): 162–167. ISSN 0028-4793. doi:10.1056/NEJM199307153290303. 
  8. Andrès E, Zimmer J, Affenberger S, Federici L, Alt M, Maloisel F. (2006). "Idiosyncratic drug-induced agranulocytosis: Update of an old disorder.". Eur J Intern Med. 17 (8): 529–35. 
  9. Levy M, Kelly JP, Kaufman DW, Shapiro S (October 1993). "Risk of agranulocytosis and aplastic anemia in relation to history of infectious mononucleosis: a report from the international agranulocytosis and aplastic anemia study". Ann. Hematol. 67 (4): 187–90. PMID 8218540. 
  10. Casato, Milyia; Pucillo, Leopoldo P.; Leoni, Marco; di Lullo, Luca; Gabrielli, Armando; Sansonno, Domenico; Dammacco, Franco; Danieli, Giovanni; Bonomo, Lorenzo (1995). "Granulocytopenia after combined therapy with interferon and angiotensin-converting enzyme inhibitors: Evidence for a synergistic hematologic toxicity". The American Journal of Medicine. 99 (4): 386–391. ISSN 0002-9343. doi:10.1016/S0002-9343(99)80186-7. 
  11. Corzo D, Yunis JJ, Salazar M, Lieberman JA, Howard A, Awdeh Z, Alper CA, Yunis EJ (November 1995). "The major histocompatibility complex region marked by HSP70-1 and HSP70-2 variants is associated with clozapine-induced agranulocytosis in two different ethnic groups". Blood. 86 (10): 3835–40. PMID 7579351. 
  12. Tamai, Hajime (1996). "Association between the DRB1*08032 Histocompatibility Antigen and Methimazole-Induced Agranulocytosis in Japanese Patients with Graves Disease". Annals of Internal Medicine. 124 (5): 490. ISSN 0003-4819. doi:10.7326/0003-4819-124-5-199603010-00005. 
  13. 13.0 13.1 Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, Wingard JR; Infectious Diseases Society of America. (2011). "Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america". Clin Infect Dis. 52 (4): e56–95. PMID 21258094. 
  14. Andrès, Emmanuel; Maloisel, Frédéric; Zimmer, Jacques (2010). "The role of haematopoietic growth factors granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor in the management of drug-induced agranulocytosis". British Journal of Haematology. ISSN 0007-1048. doi:10.1111/j.1365-2141.2010.08104.x. 
  15. Andrès, Emmanuel; Maloisel, Frédéric; Zimmer, Jacques (2010). "The role of haematopoietic growth factors granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor in the management of drug-induced agranulocytosis". British Journal of Haematology. ISSN 0007-1048. doi:10.1111/j.1365-2141.2010.08104.x. 
  16. 16.0 16.1 16.2 Andrès, Emmanuel; Zimmer, Jacques; Mecili, Mustapha; Weitten, Thierry; Alt, Martine; Maloisel, Frédéric (2014). "Clinical presentation and management of drug-induced agranulocytosis". Expert Review of Hematology. 4 (2): 143–151. ISSN 1747-4086. doi:10.1586/ehm.11.12. 
  17. Tesfa, Daniel; Keisu, Marianne; Palmblad, Jan (2009). "Idiosyncratic drug-induced agranulocytosis: Possible mechanisms and management". American Journal of Hematology. 84 (7): 428–434. ISSN 0361-8609. doi:10.1002/ajh.21433. 
  18. Schimpff S, Satterlee W, Young VM, Serpick A (1971). "Empiric therapy with carbenicillin and gentamicin for febrile patients with cancer and granulocytopenia". N Engl J Med. 284 (19): 1061–5. PMID 4994878. 
  19. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M (2006). "Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock". Crit Care Med. 34 (6): 1589–96. PMID 16625125. 
  20. Rosa RG, Goldani LZ. (2014). "Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia". Antimicrob Agents Chemother. 58 (7): 3799–803. PMID 24752269. 

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