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 Laboratory Studies Discussion Identify patients with levetiracetam induced ❖ Levetiracetam (Keppra) is a pyrrolidone derivative pancytopenia. and acts as an anti-epileptic medication by Describe management of pancytopenia induced by Fig 1 Fig 2 modulating neurotransmitter release. levetiracetam. ❖ Levetiracetam was approved by FDA for partial seizure, myoclonic seizure, and generalized tonic- Case Report clonic seizure. It is used off-label as seizure prophylaxis. ❖ This medication is associated with a few side effects Case Presentation: that include behavioral changes, headache, drowsiness, and weakness. A 79-year-old female with a medical history of hypertension, type II diabetes, and CVA who presented with MRI brain showing a ❖ Hematologic adverse effects are rarely caused by right temporoparietal mass. this therapy. These effects include anemia, thrombocytopenia, and leukopenia. Hospital Course: Fig 1:Graph depicting relationship between white blood cell count and Fig 2: Graph depicting relationship between platelet count and number ❖ Pancytopenia is a very rare adverse effect caused by ❖ Patient was started on dexamethasone prior to surgery due number of days post-operatively (POD). Levetiracetam was started on of days post-operatively (POD). Levetiracetam was started on post- levetiracetam. There are fewer than four case reports to the extensive amount of vasogenic edema. post-operative day 0 and was discontinued on post-operative day 10. operative day 0 and was discontinued on post-operative day 10. Development of leukopenia was witnessed with start of levetiracetam and Development of thrombocytopenia was witnessed with start of in the medical literature discussing the association ❖ She underwent a temporal craniotomy with resection of the improvement in leukopenia was observed with discontinuation of the levetiracetam and improvement in thrombocytopenia was observed with between levetiracetam and pancytopenia. mass. medication. discontinuation of the medication. Patient was transfused 5 units of platelet on POD 8 and POD 9. ❖ The pathogenesis behind this relationship is unclear. ❖ Levetiracetam was started off-label as seizure prophylaxis. Fig 3 ❖ Our patient developed pancytopenia induced by ❖ Postoperatively, her blood count remained stable. levetiracetam which resolved after we discontinued this medication. ❖ She was on levetiracetam, dexamethasone, pantoprazole, and enoxaparin as prophylaxis. ❖ Her hemolysis profile and blood smear did not reveal ❖ She was noted to have an episode of melena and anemia any signs of hemolysis. Therefore, we hypothesize on the fifth day postoperatively. that levetiracetam induced pancytopenia by causing bone marrow suppression. ❖ 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 Fig 4 and leukopenia. Conclusion Fig 3: Graphs depicting relationship between red blood cell count and Fig 4: Blood smear showing lack of schistocytes, and immature cell ❖ Thrombotic thrombocytopenic purpura, disseminated hemoglobin and number of days post-operatively (POD). Levetiracetam lines. Findings on blood smear correlate with absence of disseminated intravascular coagulation, and heparin-induced was started on post-operative day 0 and was discontinued on post- intravascular coagulation and thrombotic thrombocytopenic purpura, and thrombocytopenia were ruled out. operative day 10. Patient experienced an acute bleed requiring are suggestive of bone marrow suppression. transfusion of 2 units of RBC on POD 5, followed by a steady decline in ❖ Clinicians should be aware that levetiracetam ❖ Pantoprazole and enoxaparin were discontinued without Hbg and RBC. improvement in anemia was observed with discontinuation induces severe pancytopenia. any improvement in cell counts. of the medication. ❖ Clinicians should consider changing levetiracetam to ❖ The patient received a total of five units of platelets due to other agents in patients who develop pancytopenia a platelet count of less than 100,000. References with negative hemolysis profile. ❖ Levetiracetam was changed to lacosamide on day ten post- ❖ Further studies should be conducted to explain how operative, and dexamethasone was continued without levetiracetam induces bone marrow suppression and change. 1. Two new drugs for epilepsy. Med Lett Drugs Ther. 2000;42(1076):33-35. 2. Aydogan H, Yalcn S, Karahan MA, Buyukfrat E. Pancytopenia associated with levetiracetam treatment in lafora's disease. Blood Coagul Fibrinolysis. 2012;23(2): to find a diagnostic test for diagnosis. ❖ Within 24 hours of discontinuing levetiracetam, the platelet 175. doi: 10.1097/MBC.0b013e32834bdb5f [doi]. 3. Elouni B, Ben Salem C, Biour M. Levetiracetam-induced pancytopenia. Ann Pharmacother. 2009;43(5):985. doi: 10.1345/aph.1L727 [doi]. counts improved and continued to trend upward. ❖ This case will serve to spread awareness of a rare 4. Gallerani M, Mari E, Boari B, Carletti R, Marra A, Cavallo M. Pancytopenia associated with levetiracetam treatment. Clin Drug Investig. 2009;29(11):747-751. doi: cause of pancytopenia and to hypothesize how this 10.2165/11319450-000000000-00000 [doi]. ❖ A noticeable increase in white blood cells and hemoglobin 5. Sahaya K, Goyal MK, Sarwal A, Singh NN. Levetiracetam-induced thrombocytopenia among inpatients: A retrospective study. Epilepsia. 2010;51(12):2492-2495. medication causes pancytopenia. were seen five days after that. doi: 10.1111/j.1528-1167.2010.02788.x [doi]. Nasreddine W, Beydoun A. Valproate-induced thrombocytopenia: a prospective monotherapy study. Epilepsia 2008; 49: 438-45. *Equally contributed .