Bone Marrow Suppression and Its Complications After Azathioprine

Subsequent Issues Following Bone Marrow Suppression Induced by Azacitidine

Hello, Doctor Gao.
In February of this year, I visited the rheumatology and immunology department due to mild vitiligo and alopecia areata.
I was prescribed Yasmin for a month, which resulted in significant hair loss and bone marrow suppression, leading to hospitalization for a month.
During my stay, I received several white blood cell booster injections, and upon discharge on April 13, my blood test results showed a platelet count of 210,000, hemoglobin of 9.1, and white blood cell count of 3.61.
The lowest values during my hospitalization were a platelet count of 59,000 on April 4, hemoglobin of 8.8 on April 9, and a white blood cell count of 1.33 on March 24.

Two weeks after discharge, on April 22, my follow-up showed hemoglobin at 9.1, platelet count at 330,000, and white blood cell count at 5.06.
However, starting in early May, I suddenly began to experience a sensation of not being able to take a full breath.
I have no issues lying down, but when sitting or standing for a short time, I start to feel slightly short of breath.
This occurs in the afternoon and evening, while I have no problems in the morning.
Additionally, I noticed two oval-shaped lymph nodes on the left side of my neck and one symmetrical one on the right side (each about 1 cm).
I am unsure if they were present before or if they are new.
Concerned about the possibility of lymphoma, I visited the hematology and oncology department on May 19.
Blood tests showed normal values except for a drop in platelet count to 130,000.
However, the hematology department deemed it not concerning and advised me to follow up with the rheumatology department for blood cell counts.
I would like to ask the doctor why my platelet count, which was 330,000 on April 22, has now dropped again (without taking any medication in between).
Could this be due to thrombocytopenia, or is it possible that the medication has not been fully metabolized? Could the decrease in platelet count be related to lymphoma? What is the most likely possibility? Additionally, how should I interpret my breathing difficulties? I feel that my shortness of breath is related to the drop in platelet count, as it started after I began experiencing breathing difficulties.
What do you think might be happening in this situation? I apologize for my anxiety and for constantly searching for information online, which is why I am reaching out to you.

Danxin de ren, 20~29 year old female. Ask Date: 2022/05/24

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
I don't believe it's purpura.
The likelihood of lymphoma is very low because your lymph nodes are small.
It may be more likely that the side effects of the medication have not completely resolved.
Although your platelet count is somewhat low, it is still sufficient for your body, so I think there is no need for concern.
During the recovery period after medication side effects, there is still a possibility of decreased blood cell counts; as long as they do not drop too low, we would recommend simply monitoring the situation.
Regarding the symptoms of shortness of breath, after ruling out various potential causes, it may also be related to autonomic nervous system dysregulation.
This type of dysregulation can arise from previous illness, medication side effects, and post-illness anxiety.
You might consider incorporating some exercise, such as walking, to see if it improves your symptoms.
Moderate exercise can help alleviate temporary autonomic nervous system dysregulation.
Best regards from the Allergy, Immunology, and Rheumatology Department of Changhua Hospital, Ministry of Health and Welfare.

Reply Date: 2022/05/24

More Info

Bone marrow suppression is a significant concern when using immunosuppressive medications like Azathioprine. This drug is commonly prescribed for autoimmune conditions, but it can lead to various hematological complications, including leukopenia (low white blood cell count), thrombocytopenia (low platelet count), and anemia (low red blood cell count).
In your case, it appears that after starting Azathioprine, you experienced severe side effects, including significant hair loss and bone marrow suppression, which necessitated hospitalization. The blood tests you provided indicate fluctuations in your blood counts, particularly your platelet levels and hemoglobin. These fluctuations can be attributed to several factors, including the effects of the medication, your body’s response to it, and possibly the underlying condition being treated.

The drop in your platelet count from 330,000 to 130,000 after your discharge could be due to several reasons. First, it is essential to consider that bone marrow suppression can be a lingering effect of Azathioprine, even after discontinuation. The bone marrow may take time to recover fully, and during this recovery phase, platelet counts can fluctuate.
Additionally, the presence of lymph nodes that you described could indicate a reactive process, possibly due to infection or inflammation, which can also affect blood counts. While it is understandable to be concerned about the possibility of lymphatic malignancies, the normal blood tests you received from the hematology department are reassuring. However, persistent or new symptoms, such as the shortness of breath you are experiencing, should not be overlooked.

Shortness of breath can arise from various causes, including anemia, which can lead to reduced oxygen-carrying capacity in the blood. Given that your hemoglobin levels were low (9.1 g/dL), this could indeed contribute to feelings of breathlessness, especially during physical activity.
It is also important to consider other potential causes of your symptoms. For example, if you have developed an infection or if there are other underlying conditions affecting your respiratory system, these could also lead to shortness of breath.
In summary, the most likely explanations for your current situation include:
1. Residual Effects of Azathioprine: Your body may still be recovering from the effects of the medication, leading to fluctuations in blood counts and symptoms like shortness of breath.

2. Anemia: Your low hemoglobin levels could be contributing to your feelings of breathlessness, especially if you are exerting yourself.

3. Reactive Lymphadenopathy: The lymph nodes you felt could be reactive due to an infection or inflammation, which may not necessarily indicate malignancy.

4. Other Underlying Conditions: It is essential to rule out other potential causes of your symptoms, including respiratory issues or infections.

Given your concerns and the complexity of your symptoms, it is crucial to maintain close follow-up with your healthcare providers. They may recommend further investigations, such as imaging studies or additional blood tests, to monitor your condition and ensure that any potential complications are addressed promptly. If your symptoms worsen or if you experience new symptoms, do not hesitate to seek immediate medical attention.

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