Levetiracetam Induced Pancytopenia
Dana Kay DO*, Talal Alzahrani MD*, Kelly Zhang BS, Linda Lesky MD
The George Washington University, Division of General Internal Medicine
Washington, DC
Learning Objectives
Identify patients with levetiracetam induced
pancytopenia.
Describe management of pancytopenia induced by
levetiracetam.
Laboratory Studies
Fig 1
Discussion
Fig 2
❖
Levetiracetam (Keppra) is a pyrrolidone derivative
and acts as an anti-epileptic medication by
modulating neurotransmitter release.
❖
Levetiracetam was approved by FDA for partial
seizure, myoclonic seizure, and generalized tonicclonic seizure. It is used off-label as seizure
prophylaxis.
❖
This medication is associated with a few side effects
that include behavioral changes, headache,
drowsiness, and weakness.
❖
Hematologic adverse effects are rarely caused by
this therapy. These effects include anemia,
thrombocytopenia, and leukopenia.
❖
Pancytopenia is a very rare adverse effect caused by
levetiracetam. There are fewer than four case reports
in the medical literature discussing the association
between levetiracetam and pancytopenia.
❖
The pathogenesis behind this relationship is unclear.
❖
Our patient developed pancytopenia induced by
levetiracetam which resolved after we discontinued
this medication.
❖
Her hemolysis profile and blood smear did not reveal
any signs of hemolysis. Therefore, we hypothesize
that levetiracetam induced pancytopenia by causing
bone marrow suppression.
Case Report
Case Presentation:
A 79-year-old female with a medical history of hypertension, type
II diabetes, and CVA who presented with MRI brain showing a
right temporoparietal mass.
Hospital Course:
❖
Patient was started on dexamethasone prior to surgery due
to the extensive amount of vasogenic edema.
❖
She underwent a temporal craniotomy with resection of the
mass.
❖
Levetiracetam was started off-label as seizure prophylaxis.
❖
Postoperatively, her blood count remained stable.
❖
She was on levetiracetam, dexamethasone, pantoprazole,
and enoxaparin as prophylaxis.
❖
She was noted to have an episode of melena and anemia
on the fifth day postoperatively.
❖
Two units of packed red blood cell were transfused with an
appropriate response.
❖
No acute gastroenterological intervention was deemed
necessary at that time.
❖
The patient was also noted to develop thrombocytopenia
and leukopenia.
❖
Thrombotic thrombocytopenic purpura, disseminated
intravascular coagulation, and heparin-induced
thrombocytopenia were ruled out.
❖
Pantoprazole and enoxaparin were discontinued without
any improvement in cell counts.
❖
The patient received a total of five units of platelets due to
a platelet count of less than 100,000.
❖
Levetiracetam was changed to lacosamide on day ten postoperative, and dexamethasone was continued without
change.
❖
Within 24 hours of discontinuing levetiracetam, the platelet
counts improved and continued to trend upward.
❖
A noticeable increase in white blood cells and hemoglobin
were seen five days after that.
Fig 1:Graph depicting relationship between white blood cell count and
Fig 2: Graph depicting relationship between platelet count and number
number of days post-operatively (POD). Levetiracetam was started on
post-operative day 0 and was discontinued on post-operative day 10.
Development of leukopenia was witnessed with start of levetiracetam and
improvement in leukopenia was observed with discontinuation of the
medication.
of days post-operatively (POD). Levetiracetam was started on postoperative day 0 and was discontinued on post-operative day 10.
Development of thrombocytopenia was witnessed with start of
levetiracetam and improvement in thrombocytopenia was observed with
discontinuation of the medication. Patient was transfused 5 units of
platelet on POD 8 and POD 9.
Fig 3
Fig 4
Fig 3: Graphs depicting relationship between red blood cell count and
hemoglobin and number of days post-operatively (POD). Levetiracetam
was started on post-operative day 0 and was discontinued on postoperative day 10. Patient experienced an acute bleed requiring
transfusion of 2 units of RBC on POD 5, followed by a steady decline in
Hbg and RBC. improvement in anemia was observed with discontinuation
of the medication.
Conclusion
Fig 4: Blood smear showing lack of schistocytes, and immature cell
lines. Findings on blood smear correlate with absence of disseminated
intravascular coagulation and thrombotic thrombocytopenic purpura, and
are suggestive of bone marrow suppression.
❖
Clinicians should be aware that levetiracetam
induces severe pancytopenia.
❖
Clinicians should consider changing levetiracetam to
other agents in patients who develop pancytopenia
with negative hemolysis profile.
❖
Further studies should be conducted to explain how
levetiracetam induces bone marrow suppression and
to find a diagnostic test for diagnosis.
❖
This case will serve to spread awareness of a rare
cause of pancytopenia and to hypothesize how this
medication causes pancytopenia.
References
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10.2165/11319450-000000000-00000 [doi].
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*Equally contributed