Pancytopenia

A 63-year-old patient with coronary artery disease, membranous glomerulonephropathy, and a recently diagnosed gastric ulcer presented with new onset rash. The patient noticed the rash on his arms 4 weeks ago and is mostly present on his chest and arms. He is afebrile and vitals are within normal limits. The rash is not palpable (Figures 1 and 2). 

Laboratory tests. The patient was found to be pancytopenic with a white blood cell count of 0.9, a hemoglobin level of 4.8, and a platelet count of 78. The peripheral smear showed poikilocytes, predominantly acanthocytes. 

His ertythrocyte sedimentation rate was 60 and C-reactive protein count was 21.8, which raised the suspicion of vasculitis. 

Further work-up showed that antineutrophil cytoplasmic antibodies and antinuclear antibodies were negative, and serum complement C3 and C4 levels were within normal limit. The hepatitis panel was negative. 

A skin biopsy with immunofluorescence was performed—which showed no evidence of an associated perivascular or interstitial inflammatory infiltrate of significance. 

There was no evidence of leukocytoclasia, interface dermatitis, spongiosis, psoriasiform hyperplasia, or malignancy. The immunofluorescence was negative for IgG, IgA, C3, fibrinogen, and albumin.

The patient was worked up for his pancytopenia, and his B12 and folate levels were normal. His cytomegalovirus polymerase chain reaction and parvovirus IgM were negative. 

A bone marrow biopsy was done, which showed hypoplastic bone marrow; flow cytometry did not show increased blasts or any abnormality. 

The patient rash thus seemed to be due to the pancytopenia—which was most likely induced by medications. He was on mycophenolate acid for his membranous glomerulonephritis, slopidogrel bisulfate for his coronary artery disease, and pantoprazole for his gastric ulcers—all of which could have been the cause of his bone marrow suppression. His cell count improved when these medications were stopped. ■