Case Report
Disseminated Intravascular Coagulation and Immune Hemolytic Anemia, Possibly Evans Syndrome, After Oxaliplatin and Bevacizumab Infusion for Metastatic Colon Adenocarcinoma: A Case Report and Literature Review Lingjin Meng,1 Andrew Romano,1,2 Elliot Smith,1,3 Gail Macik,1,2 William W. Grosh1,2 Clinical Practice Points Oxaliplatin is a third-generation platinum derivative
widely used in combination with other chemotherapy agents to treat metastatic colorectal cancer. Common side effects include peripheral neuropathy, neutropenia, nausea, and diarrhea. We present a case of disseminated intravascular coagulation and immune hemolytic anemia, possibly Evans syndrome, immediately after oxaliplatin and
bevacizumab infusion in a 76-year-old woman with metastatic colonic adenocarcinoma. She was successfully treated with transfusion of blood products and steroids. Disseminated intravascular coagulation is a rare but life-threatening complication of oxaliplatin infusion. Overt coagulopathy and relatively few schistocytes distinguish it from thrombotic microangiopathy.
Clinical Colorectal Cancer, Vol. 14, No. 1, e1-3 ª 2015 Elsevier Inc. All rights reserved. Keywords: Coagulopathy, Drug toxicity, Hematuria, Metastatic colonic carcinoma, Renal injury, Thrombotic microangiopathy
Introduction Oxaliplatin is widely used in combination with 5-fluorouracil (FOLFOX) or capecitabine (XELOX) as the first-line treatment for metastatic colorectal cancer.1-3 The combination of oxaliplatin with 5-fluorouracil3 or capecitabine1,2 significantly improves the response rate and progression-free survival. Common side effects of oxaliplatin are sensory neuropathy (observed in approximately 80% patients who receive XELOX), neutropenia, nausea, and diarrhea.1-4 Disseminated intravascular coagulation (DIC) is a consumptive coagulopathy due to the systemic activation of the coagulation 1 Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 2 Division of Hematology and Oncology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 3 Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
Submitted: Sep 29, 2014; Accepted: Nov 11, 2014; Epub: Nov 15, 2014 Address for correspondence: William W. Grosh, MD, Department of Medicine, Division of Hematology and Oncology, University of Virginia, PO Box 800716-4276, Charlottesville, VA 22908-0716. Fax: þ1-434-243-6086; e-mail contact: [email protected]
1533-0028/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clcc.2014.11.005
cascade, hyperfibrinolysis, and the exhaustion of platelets and coagulation factors. It is commonly triggered by infection, trauma, malignancy, obstetric emergencies, and toxic insults.5 In this report we describe a case of overt DIC and immune hemolytic anemia, possibly Evans syndrome, likely induced by oxaliplatin in a 76-year-old woman with metastatic colonic adenocarcinoma.
Case Report A 76-year-old African-American woman initially presented with stage III colonic adenocarcinoma in 2009 and was treated with a number of different chemotherapy regimens subsequently due to metastasis and progression of the disease. As a result of further progression, oxaliplatin, capecitabine, and bevacizumab were begun and she tolerated her first 5 cycles very well. During her sixth cycle of chemotherapy, 4 hours into her planned infusion of oxaliplatin and bevacizumab, she developed the rapid onset of nausea, bloody emesis, abdominal pain, one episode of hematochezia, and pink-colored urine. She was immediately sent to the Emergency Department at her treating facility. Her platelets were acutely decreased from 141,000/mL before chemotherapy on the day of treatment to 16,000/mL. She was given 2 units of platelets, 2 units
Clinical Colorectal Cancer March 2015
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Disseminated Intravascular Coagulation Table 1 Relevant Laboratory Results on Admission to the Medical Intensive Care Unit Study Hemoglobina Hematocrit Platelet WBC BUNb Creatinineb Total Bilirubin AST ALT LDH Haptoglobin Protimec INRc PTTc Antithrombin III Activity D-Dimer Fibrinogen
Results
Normal Value
9.5 g/dL 27.5% 27,000/mL 25,950/mL with 19.5% bands on differential 38 mg/dL 2.4 mg/dL 3.8 mg/dL 148 U/L 25 U/L 2241 U/L 126 mg/dL 19.1 s 1.7 42.2 s 77%
11.0-18.0 g/mL 35.0%-50.0% 150,000-450,000/mL 4500-10,500/mL
45,467 ng/mL 58 mg/dL
Disseminated Intravascular Coagulation and Immune Hemolytic Anemia, Possibly Evans Syndrome, After Oxaliplatin and Bevacizumab Infusion for Metastatic Colon Adenocarcinoma: A Case Report and Literature Review Lingjin Meng,1 Andrew Romano,1,2 Elliot Smith,1,3 Gail Macik,1,2 William W. Grosh1,2 Clinical Practice Points Oxaliplatin is a third-generation platinum derivative
widely used in combination with other chemotherapy agents to treat metastatic colorectal cancer. Common side effects include peripheral neuropathy, neutropenia, nausea, and diarrhea. We present a case of disseminated intravascular coagulation and immune hemolytic anemia, possibly Evans syndrome, immediately after oxaliplatin and
bevacizumab infusion in a 76-year-old woman with metastatic colonic adenocarcinoma. She was successfully treated with transfusion of blood products and steroids. Disseminated intravascular coagulation is a rare but life-threatening complication of oxaliplatin infusion. Overt coagulopathy and relatively few schistocytes distinguish it from thrombotic microangiopathy.
Clinical Colorectal Cancer, Vol. 14, No. 1, e1-3 ª 2015 Elsevier Inc. All rights reserved. Keywords: Coagulopathy, Drug toxicity, Hematuria, Metastatic colonic carcinoma, Renal injury, Thrombotic microangiopathy
Introduction Oxaliplatin is widely used in combination with 5-fluorouracil (FOLFOX) or capecitabine (XELOX) as the first-line treatment for metastatic colorectal cancer.1-3 The combination of oxaliplatin with 5-fluorouracil3 or capecitabine1,2 significantly improves the response rate and progression-free survival. Common side effects of oxaliplatin are sensory neuropathy (observed in approximately 80% patients who receive XELOX), neutropenia, nausea, and diarrhea.1-4 Disseminated intravascular coagulation (DIC) is a consumptive coagulopathy due to the systemic activation of the coagulation 1 Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 2 Division of Hematology and Oncology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 3 Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
Submitted: Sep 29, 2014; Accepted: Nov 11, 2014; Epub: Nov 15, 2014 Address for correspondence: William W. Grosh, MD, Department of Medicine, Division of Hematology and Oncology, University of Virginia, PO Box 800716-4276, Charlottesville, VA 22908-0716. Fax: þ1-434-243-6086; e-mail contact: [email protected]
1533-0028/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clcc.2014.11.005
cascade, hyperfibrinolysis, and the exhaustion of platelets and coagulation factors. It is commonly triggered by infection, trauma, malignancy, obstetric emergencies, and toxic insults.5 In this report we describe a case of overt DIC and immune hemolytic anemia, possibly Evans syndrome, likely induced by oxaliplatin in a 76-year-old woman with metastatic colonic adenocarcinoma.
Case Report A 76-year-old African-American woman initially presented with stage III colonic adenocarcinoma in 2009 and was treated with a number of different chemotherapy regimens subsequently due to metastasis and progression of the disease. As a result of further progression, oxaliplatin, capecitabine, and bevacizumab were begun and she tolerated her first 5 cycles very well. During her sixth cycle of chemotherapy, 4 hours into her planned infusion of oxaliplatin and bevacizumab, she developed the rapid onset of nausea, bloody emesis, abdominal pain, one episode of hematochezia, and pink-colored urine. She was immediately sent to the Emergency Department at her treating facility. Her platelets were acutely decreased from 141,000/mL before chemotherapy on the day of treatment to 16,000/mL. She was given 2 units of platelets, 2 units
Clinical Colorectal Cancer March 2015
- e1
Disseminated Intravascular Coagulation Table 1 Relevant Laboratory Results on Admission to the Medical Intensive Care Unit Study Hemoglobina Hematocrit Platelet WBC BUNb Creatinineb Total Bilirubin AST ALT LDH Haptoglobin Protimec INRc PTTc Antithrombin III Activity D-Dimer Fibrinogen
Results
Normal Value
9.5 g/dL 27.5% 27,000/mL 25,950/mL with 19.5% bands on differential 38 mg/dL 2.4 mg/dL 3.8 mg/dL 148 U/L 25 U/L 2241 U/L 126 mg/dL 19.1 s 1.7 42.2 s 77%
11.0-18.0 g/mL 35.0%-50.0% 150,000-450,000/mL 4500-10,500/mL
45,467 ng/mL 58 mg/dL
