Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China.
Department of Pharmacy, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China.
BMC Infect Dis. 2024 Oct 4;24(1):1105. doi: 10.1186/s12879-024-09949-y.
Vancomycin-induced bleeding has been reported, attributed to the mechanism of immune thrombocytopenia. A rare case of vancomycin-induced gastrointestinal hemorrhage in a young patient with no underlying disease, receiving intravenous vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) infection, is presented. This occurrence occurred without thrombocytopenia. Relevant cases reported in the literature were also reviewed.
A 34-year-old male patient presented with maxillofacial multiple spaces infection accompanying left temporal abscess, bilateral lung abscesses. Culture results from both blood and secretion indicated that the infection was caused by MRSA. The patient received standard-dose vancomycin (1 g q12h intravenously guttae) for treatment. On the 5th day of therapy, he presented with bright red blood in his stool; however, vancomycin treatment was continued. By the 9th day, a decrease in hemoglobin level to 76 g/L and a platelet (PLT) count of 424 × 10/L raised concerns about gastrointestinal hemorrhage. The hemoglobin level decreased to 62 g/L on day 12. Due to the high tissue concentration of linezolid, administration of linezolid at a dose of 600 mg q12h intravenously guttae commenced on the 13th day as an alternative to vancomycin(D13-D17). Subsequently, on the 17th day, there was an improvement in hemoglobin level to 78 g/L. However, despite treatment with linezolid, the patient's fever showed no significant improvement, prompting a switch back to vancomycin at a dosage of 1 g q12h intravenously guttae(D18-D22). On the 21st day, there was a recurrence of gastrointestinal hemorrhage, accompanied by a hemoglobin level of 42 g/L and a PLT count of 224 × 10/L. Gastroscopy revealed the presence of a gastroduodenal ulcer. The patient had no prior history of hemorrhoids, gastrointestinal ulcers, liver cirrhosis, or purpura. Prior to admission, he had not been administered non-steroidal anti-inflammatory drugs (NSAIDs) or steroids. During hospitalization, the only medications given were vancomycin, ambroxol and lidocaine. Additional tests ruled out immunological disorders as the cause of gastrointestinal ulcers, and a positive vancomycin rechallenge test indicated an association between vancomycin and bleeding. After discontinuation of vancomycin, no further bleeding occurred. This case highlights a rare occurrence of vancomycin-induced bleeding without thrombocytopenia, classified as "Certain" according to the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale for standardized case causality assessment.
This case represents the first documented instance of vancomycin-induced bleeding without thrombocytopenia, as confirmed by a positive rechallenge test. This discovery will aid in the early detection of this rare adverse reaction in future cases.
已有报道称万古霉素可引起出血，其机制与免疫性血小板减少症有关。本文报告一例无基础疾病的年轻患者，因耐甲氧西林金黄色葡萄球菌（MRSA）感染接受静脉万古霉素治疗后发生罕见的胃肠道出血，且无血小板减少。还回顾了文献中报道的相关病例。
一名 34 岁男性患者因颌面多间隙感染伴左侧颞部脓肿、双侧肺脓肿就诊。血和分泌物的培养结果均表明感染由 MRSA 引起。患者接受标准剂量万古霉素（1g，q12h 静脉滴注）治疗。治疗第 5 天，患者出现大便鲜红血，但继续给予万古霉素治疗。第 9 天，血红蛋白降至 76g/L，血小板（PLT）计数降至 424×10/L/L，引起对胃肠道出血的关注。第 12 天，血红蛋白降至 62g/L。由于利奈唑胺的组织浓度高，第 13 天开始给予利奈唑胺（600mg，q12h 静脉滴注）替代万古霉素（D13-D17）。随后，第 17 天，血红蛋白水平改善至 78g/L。然而，尽管使用了利奈唑胺，患者的发热仍无明显改善，促使再次切换回万古霉素（1g，q12h 静脉滴注）（D18-D22）。第 21 天，患者再次出现胃肠道出血，伴有血红蛋白水平 42g/L 和 PLT 计数 224×10/L。胃镜检查显示胃十二指肠溃疡。患者既往无痔疮、胃肠道溃疡、肝硬化或紫癜病史。入院前，未给予非甾体抗炎药（NSAIDs）或皮质类固醇。住院期间，仅给予万古霉素、氨溴索和利多卡因。进一步检查排除了免疫性疾病是胃肠道溃疡的原因，阳性的万古霉素再激发试验表明万古霉素与出血之间存在关联。停止万古霉素后，未再发生出血。本病例提示了一种罕见的无血小板减少的万古霉素引起的出血，根据世界卫生组织-乌普萨拉监测中心（WHO-UMC）标准化病例因果关系评估量表，其严重程度分类为“肯定”。
本病例是首例经阳性再激发试验证实的无血小板减少的万古霉素引起的出血，有助于在未来病例中早期发现这种罕见的不良反应。
