氯吡格雷相关非重型再生障碍性贫血

Non-severe aplastic anemia associated with clopidogrel

1例66岁男性患者因心肌梗死入院,并立即行经皮冠状动脉腔内成形术及支架术。术后当日规律口服氯吡格雷75 mg,1次/d;阿司匹林首剂量300 mg,之后100 mg,1次/d;氟伐他汀20 mg,1次/d;福辛普利钠10 mg,1次/d。1个月后,患者出现寒战、高热。血常规检查:白细胞1.1×109/L,中性粒细胞0.034,中性粒细胞绝对值0.037×109/L,红细胞3.6×1012/L,血红蛋白113 g/L,血小板119×109/L。骨髓穿刺及活检示非重型再生障碍性贫血。给予对症治疗,血常规各项水平继续下降。入院第44天血常规检查:白细胞2.6×109/L,中性粒细胞0.367,中性粒细胞绝对值0.954×109/L,红细胞3.6×1012/L,血红蛋白113 g/L,血小板84×109/L。立即停用氯吡格雷及阿司匹林,改用华法林2.5 mg,1次/d口服,西洛他唑100 mg,2次/d口服,其他药物继续服用。随后血常规检查示全血细胞计数下降至最低值后逐渐上升。再行2次骨髓穿刺检查,结果示骨髓象逐渐恢复。入院第102天血常规检查:白细胞5.8×109/L,中性粒细胞0.552,中性粒细胞绝对值3.202×109/L,红细胞4.2×1012/L,血红蛋白140 g/L,血小板170×109/L。再次加用氯吡咯雷50 mg,1次/d;阿司匹林100 mg,1次/d。1周后血常规检查示全血细胞计数明显下降,2周后血常规检查:白细胞3.4×109/L,中性粒细胞0.349,中性粒细胞绝对值1.187×109/L,红细胞4.0×1012/L,血红蛋白133 g/L,血小板176×109/L。随后,仅停用氯吡咯雷,改为西洛他唑100 mg,3次/d口服。1周后血象恢复正常。

A 66-year-old man with myocardial infarction was hospitalized and underwent percutaneous transluminal coronary angioplasty and stenting immediately.The day after surgery,he received clopidogrel 75 mg once daily,intial dose of aspirin 300 mg followed by 100 mg per day,fluvastatin 20 mg once daily,and fosinopril sodium 10 mg once daily.One month later,the patient developed chills and high fever.Routine blood tests revealed the following values： white blood cell count 1.1×109/L with neutrophils 0.034,absolute value of neutrophils 0.037×109/L,red blood cell count 3.6×1012/L,hemoglobin 113 g/L,and platelet count 119×109/L.Bone marrow aspiration and biopsy showed non-severe aplastic anemia.He received symptomatic treatment,his routine blood tests showed marked decreases in his complete blood count.On day 44 of hospitalization,routine blood tests revealed the following values： white blood cell count 2.6×109/L with neutrophils 0.367,absolute value of neutrophils 0.954×109/L,red blood cell count 3.6×1012/L,hemoglobin 113 g/L,and platelet count 84×109/L.Clopidogrel and aspirin were withdrawn immediately and switched to warfarin 2.5 mg once daily and cilostazol 100 mg twice daily,other medicines continued also.Subsequently,the routine blood tests were performed,and complete blood count gradually increased after reaching the lowest values.Bone marrow aspiration was repeated two times and results showed that bone marrow picture gradually returned to normal.On day 102 of hospitalization,routine blood tests revealed the following values： white blood cell count 5.8×109/L with neutrophils 0.552,absolute value of neutrophils 3.202×109/L,red blood cell count 4.2×1012/L,hemoglobin 140 g/L,and platelet count 170×109/L.He was prescribed clopidogrel 50 mg once daily,aspirin 100 mg once daily.One week later,his routine blood tests showed marked decreases in complete blood count and,two weeks later,routine blood tests revealed the following values： white blood cell count 3.4×109/L with neutrophils 0.349,absolute value of neutrophils 1.187×109/L,red blood cell count 4.0×1012/L,hemoglobin 133 g/L,and platelet count 176×109/L.Subsequently,clopidogrel alone was stopped and changed to cilostazol 100 mg thrice daily.After one week,his blood picture normalized.