Azathioprine-induced Pancytopenia Leading to Mucormycosis in a Patient - Case Report

Azathioprine-induced Pancytopenia Leading to Mucormycosis in a Patient - Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Azathioprine-induced Pancytopenia Leading to Mucormycosis in a Patient - Case Report Arun S, Durga Shankar Meena, Shoban Babu Vartha, Sneha Ambwani, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4226253/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract It is evident from the previous literature that azathioprine an immunomodulator drug used for the pharmacotherapy of inflammatory bowel disease is prone to severe myelosuppression in the susceptible population. If TPMT genetic polymorphism is there it is related to the myelosuppression related to the drug azathioprine and it is linked with the metabolism of the azathioprine. In this case, a 46-year-old male patient after a short 20-day course of azathioprine for the inflammatory disease presented with fever and swelling of the face on evaluation pancytopenia was revealed, and later on further detailed evaluation, he was diagnosed with Mucormycosis. During the hospital stay, he was treated with Posaconazole and Amphotericin b liposomal preparation for the mucormycosis, and his WBC count remained normal, but the hemoglobin level remained low at 7.2 g/dl at the time of discharge. The Initial incidence of pancytopenia induced by the azathioprine and persistence of the anemia and thrombocytopenia may be due to the administration of the posaconazole for the mucormycosis. Azathioprine thiopurine methyl transferase mucormycosis Posaconazole Figures Figure 1 Figure 2 INTRODUCTION Mucormycosis is one of the morbid invasive fungal infections seen in opportunistic patients, especially during the COVID-19 pandemic. It can occur in other patients who are immunocompromised. If a patient is taking immunosuppressants for any of the diseases or the autoimmune disorders or components like inflammatory disorders treated with either immunomodulatory or immunosuppressant drugs. One of the drugs used for the therapy of inflammatory bowel disease is Azathioprine. Azathioprine is a drug that is metabolized with TPMT and the xanthine oxidase, hypoxanthine-guanine phosphoribosyl transfer enzymes. If there are genetic polymorphisms that determine the metabolism of the azathioprine that may lead to toxicity related to the azathioprine like severe myelosuppression including anemia, thrombocytopenia, and leukopenia. CASE REPORT The 46-year-old male patient was admitted to the medical trauma ward of AIIMS from 07.11.2022 to 08.12.2022 with a diagnosed case of Pulmonary and Sinonasal Mucormycosis . He was referred from the peripheral hospital with complaints of fever and cough for the past 8 days and with pancytopenia as per the investigations done there. He has a history of blood in stool for which underwent colonoscopic and biopsy and was diagnosed with Acute infective ulcerative colitis and treated with mesalamine and Azathioprine (50 mg two times daily) for 20 days from 06.10.2022 to 24.10 .2022. Then after 6 days he was admitted to another hospital with complaints of fever and facial swelling and treated with meropenem there, but counts for both RBC, WBC And platelets were decreasing progressively in the admission period i.e from Hb-9.30g/dl, WBC- 1000/microliter, Platelets- 1,27,000/microliter, RBC-2.95laks cells/microliter on 01.11.2022 to Hb- 7.2g/dl, WBC-600cells/microliter Platelet count-41000 cells/microliter on 06.11.2022 (Figure 2 and Table 1) and he was referred to AIIMS Jodhpur for further evaluation and management. After the 20-day course of azathioprine and after 5-6 days developed the pancytopenia. At the presentation, he also had a cough and b/l crepitations present. On examination patient had pallor and the rest of the examination did not reveal any abnormality. Routine investigations were sent which showed pancytopenia with febrile neutropenia, raised inflammatory markers, Ferritin levels elevated, elevated fibrinogen, and low reticulocyte count. The patient was started on broad-spectrum antibiotics for febrile neutropenia. A bone marrow biopsy was done which was normal. The nasal swab KOH of the patient showed the presence of mucor, As reported by the Radiologist, CE-MRI PNS showed heterogenous enhancing mucosal thickening suggestive of invasive fungal sinusitis. The patient underwent debridement for mucormycosis. Chest x-ray showed bilateral haziness. CMV PCR sent outside came back negative. Bone marrow cultures were also sterile. On 3 rd week of November patient underwent colonoscopy and endoscopy which revealed multiple ulcers in colonoscopy and a small hiatus hernia in Endoscopy. MRI findings were suggestive of pulmonary mucormycosis also. Debridement for the mucor was done by ENT on the fourth week of November. One PRBC pre-procedure on the third week and 2 after the procedure given. The patient initially started on Inj Piperacillin+ tazobactam 4.5 gm and later switched to Inj Meropenem 1gm IV three times daily, Inj Teicoplanin 40 mg IV twice daily and other drugs like tramadol and pantoprazole, and treatment continued with same drugs till the end of the second week of November. After the diagnosis of mucormycosis and started Inj Amphotericin (liposomal) B 500mg IV in 1pint D5% as 100ml/hour infusion, Tab Posaconazole 300 mg PO once daily, Inj KCL 2amp in 500 ml IV infusion 100ml/hr along with meropenem continued till 4 th week of November. The patient was given Magnesium sulfate infusion in between and amoxicillin clavulanic acid replaced meropenem after surgical debridement. The rest of the therapy with Inj Amphotericin and Posaconazole continued till the discharge. Amphotericin dose reduction is needed in the first week of January due to deranged renal function. ( Table 3) .After the first week of December. patient discharged on Tab Posaconazole 300 mg Once daily with other symptomatic treatment. On the periodic follow-up in the 1 st , 2 nd , and 3 rd months patient hemoglobin gradually recovered from 7.9 gm/dl to 11.4 gm/dl ( Figure 2 and Table 1). Other parameters within normal limits including the liver function test ( Table 2) On follow-up investigation done the TPMT polymorphism revealed wild type of mutation as *1/*1 genotype . DISCUSSION Patient with fever, cough, and pancytopenia after the short period of treatment with Azathioprine for the inflammatory bowel disease. It is evident from the previous studies in the literature search that azathioprine-induced pancytopenia is not uncommon and it is typically found associated with the specific single nucleotide genetic polymorphism of the TPMT related to the metabolism of the azathioprine. The antecedent incidence of mucormycosis in this patient may be secondary to immunosuppression caused by azathioprine and the added effect of pancytopenia caused by the azathioprine. The continuation of the therapy for the mucormycosis with posaconazole and amphotericin B may have contributed to the sustenance of the pancytopenia, especially anemia and thrombocytopenia. On reviewing the hematological parameters of the patient from October before the starting of the azathioprine hemoglobin (14.6gm/dl), the total WBC count and platelet count were within normal limits. After 20 days of treatment with azathioprine for the inflammatory bowel disease patient count dropped to initially 9.4 gm/dl hemoglobin and in the subsequent 6 days it dropped to 6.6gm/dl along with a count drop of the total WBC count and platelet count. The patient also presented with facial swelling and fever for which he has been treated with IV antibiotics and which was not responded to initially and later on further workup was diagnosed to be mucormycosis. Only after initiation with the amphotericin and Posaconazole did the symptoms of the patient improve but the anemia, thrombocytopenia, and leukopenia continued even after starting the antifungal agents. This prolonged myelosuppression may be due to the bone marrow suppression by the initial azathioprine therapy which may be prolonged due to the added effect on the bone marrow by the Posaconazole therapy. The previous review noted that some genetic polymorphism of TPMT is associated with more incidence of myelosuppression secondary to the intake of azathioprine for inflammatory bowel disease. A case report of azathioprine-induced pancytopenia in a 63-year-old female with ischemic optic neuropathy treated with initial oral methylprednisolone followed by oral azathioprine 25 mg twice daily initially and followed by increasing the dose to 50 mg twice daily presented with acute stroke and low level of total blood counts, with a causality association (Naranjo scoring ) of 6(1). Another case report published by Hadda V et al in the Journal of Postgraduate Medicine in 2009 described the incidence of azathioprine-induced febrile neutropenia and severe bone marrow depression in a 23-year-old male with lupus nephritis when he started on the azathioprine as maintenance therapy after a six-month course of cyclophosphamide. (2). In a retrospective analysis of 93 adults with IBD and azathioprine therapy published in the Pharmacogenetics and Genomics journal in August 2002, In the concerned study both phenotyping and genotyping were used for correlating TPMT and azathioprine-related adverse reactions. In the study 69 patients receiving azathioprine never experienced side effects, 10 patients had the therapy withdrawn due to nonmedical reasons, and 14 patients (15%) had stopped medications or were on reduced doses due to azathioprine-related serious side effects. TPMT deficiency in one patient had led to pancytopenia whereas only two of the remaining four patients with hematotoxicity displayed an intermediate phenotype of TPMT. This study demonstrates that azathioprine-related gastrointestinal side effects are independent of the TPMT polymorphism. However, the study suggests the usage of the TPMT polymorphism for the recognition of the hematological toxicity of azathioprine due to heterozygous TPMT polymorphism. (3) Azathioprine is a prodrug of the 6 mercaptopurine and in the blood, it is converted into 6 mercaptopurine non-enzymatically and further metabolism by enzyme systems to metabolites like thiouric acid, 6 methyl mercaptopurine, 6 thioguanine. Hypoxanthine guanine phosphoribosyl transferase (HGPRT) and thiopurine methyl transferase (TPMT) are the key enzymes involved in the metabolism of azathioprine. (Figure 1) These metabolites if produced in higher concentration may lead to various toxicities like myelotoxicity or hepatotoxicity depending on the metabolites produced more. This metabolism in turn influenced by the TPMT genetic polymorphism and and resultant variant TPMT proteins (enzymes) which may be either higher activity or lower activity than the normal population. Higher TPMT activity leads to elevated levels of 6 methyl mercaptopurine owing to hepatotoxicity. On the other hand, lower TPMT activity leads to more production of 6 thioguanine which leads to severe myelotoxicity. According to the studies TPMT has high activity, intermediate activity, and low activity variants according to the genetic polymorphism affecting the single nucleotide mutation. TPMT with low activity leads to myelotoxicity. The other gene influencing the metabolism of azathioprine is the NUDT15 (nudix hydrolase 15) gene. NUD15 hydrolysis the 5 thioguanine triphosphate into less active 5 thioguanine monophosphate. So a decreased activity of the NUD15 gene is associated with more myelotoxicity.(4) ,(5),(6). A meta-analysis conducted by Gennep S et al found a significantly higher thiopurine-induced leukopenia risk for TPMT with an odd ratio of 3.9 (95% CI 2.5-6.1) and for NUDT15 R139 with an odds ratio of 6.9, (95% CI 5.2-9.1). G52A & 36_37ins/delGGAGTC variant carriers with odds ratios of 3.2 and 5.6 respectively also identified. A potential association between high 6-thioguanine nucleotides (6-TGN) or 6-methyl mercaptopurine (6-MMP) levels and leukopenia was also identified from the analysis.(7) From the evidence generated it could be inferred that the pancytopenia in this patient was caused by the azathioprine and led to the immunosuppressed status and mucormycosis occurring and sustenance of the pancytopenia due to the effect of the drug posaconazole. CONCLUSION The clinical scenario of the patients gives an inference that initial azathioprine therapy possibly leads to bone marrow suppression manifested as prolonged pancytopenia especially anemia owing to immunosuppression and resulted in mucormycosis. But even after starting the specific treatment for mucormycosis the anaemia continued till the discharge of the patient and it was only resolved after 3 months. So, these hind two things one is the bone marrow suppression due to the azathioprine resulting in prolonged myelosuppression due to some mechanisms or the second thing to be kept in mind is that adding the Posaconazole and continuing the Posaconazole after the discharge may add on the bone marrow depression that’s why the recovery from anemia was prolonged. The association of the TPMT and NUD15 cannot be identified as the genotyping and phenotyping for the concerned gene not done in this patient. So, the take-home message of this case scenario is that using azathioprine and 6 Mercaptopurine-like drugs for the inflammatory bowel disease or any other indication ideally warrants the meticulous monitoring of the hematological parameters periodically and if possible single nucleotide genetic polymorphism of the TPMT and NUD15 can be done before initiating the therapy. This like events warrant the introduction of TPMT testing as a routine test in the susceptible population as a part of guidelines and resources for the testing TPMT should be made available. STRENGTH AND LIMITATION OF THE STUDY: This case report identifies the myelosuppression secondary to azathioprine therapy for a short period and leading to the mucormycosis secondary to either immunomodulation or immunosuppression in a relatively healthy individual. This warrants the routine use of either the periodic blood testing in resource poor centers or TPMT and NUD15 gene testing for predicting the azathioprine induced myelosuppression in the resource rich centers as a policy decision to prevent severe myelosuppression secondary to azathioprine or 6 mercaptopurine. We have not done the TPMT /NUD15 genotyping due to nonavailability of testing facility. So, association between the TPMT /NUD15 genotypic variant is not confirmed, it needs further investigations. Abbreviations TPMT- thiopurine methyl transferase NUD15- nudix hydrolase 15 CMV- Cytomegalovirus CE- MRI- Contrast-Enhanced Magnetic Resonance Imaging Declarations ETHICAL APPROVAL AND CONSENT TO PARTICIPATE: A waiver for ethics committee approval has been obtained from the institute due to the nature of the article being a case series All the authors confirm that the patient consent form has been obtained from this patient. CONSENT FOR PUBLICATION: Written informed consent was obtained from the patients for publication of this case series and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal AVAILABILITY OF DATA AND MATERIALS: Data sharing does not apply to this article as no datasets were generated or analysed during the current study. All necessary information related to the case report has been provided in the article. Waiver from the Ethics Committee and the patient’s consent form will be provided upon reasonable request to the corresponding author COMPETING INTERESTS: The authors declare that they have no competing interests. FUNDING: The authors declare that there was no funding source for this work. AUTHORS' CONTRIBUTIONS: Case clinical scenario and adverse drug event monitored by initiated the conception of the case report. Case report written by AS, DS, SA, SB, JK, M, GK. Discussion and possible relations of the case scenario and adverse drug event inferred by AS, DS, SA, SB, JK,M,GK. Consent taken by AS and M . All authors read and approved the final manuscript. ACKNOWLEGEMENT: We extend our heartfelt appreciation to Dr.Anoop Pratheesh P, Surgeon in the Government Health Services, Kerala, Dr. G. Krishnakumar, Physician and Intensivist at Dr. Govindans Hospital Thiruvananthapuram, Dr Surjith Singh Professor Pharmacology, and all the Consultants and Senior residents and Junior residents especially Dr Akaash of the Department of General Medicine , Radiology department and Microbiology Department involved in the treatment of Patient and For supporting the writing and suggestions for their invaluable suggestions and unwavering support, which have greatly enriched the quality and depth of our study. References Philip JM, C. P, George C, Vijayan M. AZATHIOPRINE INDUCED PANCYTOPENIA-A CASE REPORT. Int J Pharm Pharm Sci. 2017 Feb 1;9(2):324. Hadda V, Pandey B, Gupta R, Goel A. Azathioprine induced pancytopenia: A serious complication. J Postgrad Med. 2009;55(2):139. Schwab M, Schäffeler E, Marx C, Fischer C, Lang T, Behrens C, et al. Azathioprine therapy and adverse drug reactions in patients with inflammatory bowel disease: impact of thiopurine S-methyltransferase polymorphism. Pharmacogenetics. 2002 Aug;12(6):429–36. Moriyama T, Nishii R, Perez-Andreu V, Yang W, Klussmann FA, Zhao X, et al. NUDT15 polymorphisms alter thiopurine metabolism and hematopoietic toxicity. Nat Genet. 2016 Apr;48(4):367–73. Yang JJ, Landier W, Yang W, Liu C, Hageman L, Cheng C, et al. Inherited NUDT15 Variant Is a Genetic Determinant of Mercaptopurine Intolerance in Children With Acute Lymphoblastic Leukemia. J Clin Oncol. 2015 Apr 10;33(11):1235–42. Walker GJ, Harrison JW, Heap GA, Voskuil MD, Andersen V, Anderson CA, et al. Association of Genetic Variants in NUDT15 With Thiopurine-Induced Myelosuppression in Patients With Inflammatory Bowel Disease. JAMA. 2019 Feb 26;321(8):773. van Gennep S, Konté K, Meijer B, Heymans MW, D’Haens GR, Löwenberg M, et al. Systematic review with meta-analysis: risk factors for thiopurine-induced leukopenia in IBD. Aliment Pharmacol Ther. 2019 Sep;50(5):484–506. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4226253","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289787517,"identity":"89df8b09-9c26-4cbe-b79a-06ead4586e0f","order_by":0,"name":"Arun S","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Arun","middleName":"","lastName":"S","suffix":""},{"id":289787518,"identity":"9cf57421-ed3d-4cce-97f1-0e699da15023","order_by":1,"name":"Durga Shankar Meena","email":"","orcid":"","institution":"All India Institute of Medical Sciences 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2","display":"","copyAsset":false,"role":"figure","size":384592,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMyelosuppression trends induced by Azathioprine in a Mucormycosis patient.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"FIGURE2.AZATHIOPRINEINDUCEDMYELOSUPPRESIONPATTERNINAMUCORMYCOSISPATIENT.png","url":"https://assets-eu.researchsquare.com/files/rs-4226253/v1/f9ebfd4a0666b79de73ecf4a.png"},{"id":62322031,"identity":"6f294a35-08fd-4467-aa7b-dc9e583f4ad5","added_by":"auto","created_at":"2024-08-13 01:57:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":796909,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4226253/v1/bc6ec63b-2f55-48c1-a5d8-3e5662d38644.pdf"},{"id":62321394,"identity":"5d0690e4-9276-4868-a0cd-42460f730f1b","added_by":"auto","created_at":"2024-08-13 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It can occur in other patients who are immunocompromised. If a patient is taking immunosuppressants for any of the diseases or the autoimmune disorders or components like inflammatory disorders treated with either immunomodulatory or immunosuppressant drugs. One of the drugs used for the therapy of inflammatory bowel disease is Azathioprine. Azathioprine is a drug that is metabolized with TPMT and the xanthine oxidase, hypoxanthine-guanine phosphoribosyl transfer enzymes. If there are genetic polymorphisms that determine the metabolism of the azathioprine that may lead to toxicity related to the azathioprine like severe myelosuppression including anemia, thrombocytopenia, and leukopenia.\u003c/p\u003e"},{"header":"CASE REPORT ","content":"\u003cp\u003eThe 46-year-old male patient was admitted to the medical trauma ward of AIIMS from 07.11.2022 to 08.12.2022 with a diagnosed case of \u003cstrong\u003ePulmonary and Sinonasal Mucormycosis\u003c/strong\u003e. He was referred from the peripheral hospital with complaints of fever and cough for the past 8 days and with pancytopenia as per the investigations done there. He has a history of blood in stool for which underwent colonoscopic and biopsy and was diagnosed with Acute infective ulcerative colitis and treated with mesalamine and Azathioprine (50 mg two times daily) for 20 days from 06.10.2022 to 24.10 .2022. Then after 6 days he was admitted to another hospital with complaints of fever and facial swelling and treated with meropenem there, but counts for both RBC, WBC And platelets were decreasing progressively in the admission period i.e from Hb-9.30g/dl, WBC- 1000/microliter, Platelets- 1,27,000/microliter, RBC-2.95laks cells/microliter on 01.11.2022 to Hb- 7.2g/dl, WBC-600cells/microliter Platelet count-41000 cells/microliter on 06.11.2022 (Figure 2 and Table 1) and he was referred to AIIMS Jodhpur for further evaluation and management. After the 20-day course of azathioprine and after 5-6 days developed the pancytopenia.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;At the presentation, he also had a cough and b/l crepitations present. On examination patient had pallor and the rest of the examination did not reveal any abnormality. Routine investigations were sent which showed pancytopenia with febrile neutropenia, raised inflammatory markers, Ferritin levels elevated, elevated fibrinogen, and low reticulocyte count. The patient was started on broad-spectrum antibiotics for febrile neutropenia. A bone marrow biopsy was done which was normal. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe nasal swab KOH of the patient showed the presence of mucor, As reported by the Radiologist, CE-MRI PNS showed heterogenous enhancing mucosal thickening suggestive of invasive fungal sinusitis. The patient underwent debridement for mucormycosis. Chest x-ray showed bilateral haziness. CMV PCR sent outside came back negative. Bone marrow cultures were also sterile. On 3\u003csup\u003erd\u003c/sup\u003e week of November patient underwent colonoscopy and endoscopy which revealed multiple ulcers in colonoscopy and a small hiatus hernia in Endoscopy. MRI findings were suggestive of pulmonary mucormycosis also. Debridement for the mucor was done by ENT on the fourth week of November. One PRBC pre-procedure on the third week and 2 after the procedure given.\u003c/p\u003e\n\u003cp\u003eThe patient initially started on \u0026nbsp;Inj Piperacillin+ tazobactam 4.5 gm and later switched to Inj Meropenem 1gm IV three times daily, Inj Teicoplanin 40 mg IV twice daily and other drugs like tramadol and pantoprazole, and treatment continued with same drugs till the end of the second week of November. After the diagnosis of mucormycosis and started Inj Amphotericin (liposomal) B 500mg IV in 1pint D5% as 100ml/hour infusion, Tab Posaconazole 300 mg PO once daily, Inj KCL 2amp in 500 ml IV infusion 100ml/hr along with meropenem continued till 4\u003csup\u003eth\u003c/sup\u003e week of November. The patient was given Magnesium sulfate infusion in between and amoxicillin clavulanic acid replaced meropenem after surgical debridement. The rest of the therapy with Inj Amphotericin and Posaconazole continued till the discharge. Amphotericin dose reduction is needed in the first week of January due to deranged renal function. (\u003cstrong\u003e\u003cem\u003eTable 3)\u003c/em\u003e\u003c/strong\u003e.After the first week of December. patient discharged on Tab Posaconazole 300 mg Once daily with other symptomatic treatment. On the periodic follow-up in the 1\u003csup\u003est\u003c/sup\u003e, 2\u003csup\u003end\u003c/sup\u003e, and 3\u003csup\u003erd\u003c/sup\u003e months patient hemoglobin gradually recovered from 7.9 gm/dl to 11.4 gm/dl\u003cem\u003e(\u003cstrong\u003eFigure 2 and Table 1).\u003c/strong\u003e\u003c/em\u003e Other parameters within normal limits including the liver function test (\u003cstrong\u003e\u003cem\u003eTable 2)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn follow-up investigation done the TPMT polymorphism revealed wild type of mutation as \u003cstrong\u003e\u003cem\u003e*1/*1 genotype\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u0026nbsp;Patient with fever, cough, and pancytopenia after the short period of treatment with Azathioprine for the inflammatory bowel disease. It is evident from the previous studies in the literature search that azathioprine-induced pancytopenia is not uncommon and it is typically found associated with the specific single nucleotide genetic polymorphism of the TPMT related to the metabolism of the azathioprine. The antecedent incidence of mucormycosis in this patient may be secondary to immunosuppression caused by azathioprine and the added effect of pancytopenia caused by the azathioprine. The continuation of the therapy for the mucormycosis with posaconazole and amphotericin B may have contributed to the sustenance of the pancytopenia, especially anemia and thrombocytopenia.\u003c/p\u003e\n\u003cp\u003eOn reviewing the hematological parameters of the patient from October before the starting of the azathioprine hemoglobin (14.6gm/dl), the total WBC count and platelet count were within normal limits. After 20 days of treatment with azathioprine for the inflammatory bowel disease patient count dropped to initially 9.4 gm/dl hemoglobin and in the subsequent 6 days it dropped to 6.6gm/dl along with a count drop of the total WBC count and platelet count. The patient also presented with facial swelling and fever for which he has been treated with IV antibiotics and which was not responded to initially and later on further workup was diagnosed to be mucormycosis. Only after initiation with the amphotericin and Posaconazole did the symptoms of the patient improve but the anemia, thrombocytopenia, and leukopenia continued even after starting the antifungal agents. This prolonged myelosuppression may be due to the bone marrow suppression by the initial azathioprine therapy which may be prolonged due to the added effect on the bone marrow by the Posaconazole therapy.\u003c/p\u003e\n\u003cp\u003eThe previous review noted that some genetic polymorphism of TPMT is associated with more incidence of myelosuppression secondary to the intake of azathioprine for inflammatory bowel disease. A case report of azathioprine-induced pancytopenia in a 63-year-old female with ischemic optic neuropathy treated with initial oral methylprednisolone followed by oral azathioprine 25 mg twice daily initially and followed by increasing the dose to 50 mg twice daily presented with acute stroke and low level of total blood counts, with a causality association (Naranjo scoring ) of 6(1).\u0026nbsp; Another case report published by\u0026nbsp;Hadda V et al in the Journal of Postgraduate Medicine in 2009 described the incidence of azathioprine-induced febrile neutropenia and severe bone marrow depression in a 23-year-old male with lupus nephritis when he started on the azathioprine as maintenance therapy after a six-month course of cyclophosphamide.\u0026nbsp;(2).\u0026nbsp;In a retrospective analysis of 93 adults with IBD and azathioprine therapy published in the Pharmacogenetics and Genomics journal in August 2002, In the concerned study both phenotyping and genotyping were used for correlating TPMT and azathioprine-related adverse reactions. In the study 69 patients receiving azathioprine never experienced side effects, 10 patients had the therapy withdrawn due to nonmedical reasons, and 14 patients (15%) had stopped medications or were on reduced doses due to azathioprine-related serious side effects. \u0026nbsp;TPMT deficiency in one patient had led to pancytopenia whereas only two of the remaining four patients with hematotoxicity displayed an intermediate phenotype of TPMT. This study demonstrates that azathioprine-related gastrointestinal side effects are independent of the TPMT polymorphism. However, the study suggests the usage of the TPMT polymorphism for the recognition of the hematological toxicity of azathioprine due to heterozygous TPMT polymorphism.\u0026nbsp;(3)\u003c/p\u003e\n\u003cp\u003eAzathioprine is a prodrug of the 6 mercaptopurine and in the blood, it is converted into 6 mercaptopurine non-enzymatically and further metabolism by enzyme systems to metabolites like thiouric acid, 6 methyl mercaptopurine, 6 thioguanine. Hypoxanthine guanine phosphoribosyl transferase (HGPRT) and thiopurine methyl transferase (TPMT) are the key enzymes involved in the metabolism of azathioprine. \u003cstrong\u003e\u003cem\u003e(Figure 1)\u003c/em\u003e\u003c/strong\u003e These metabolites if produced in higher concentration may lead to various toxicities like myelotoxicity or hepatotoxicity depending on the metabolites produced more. This metabolism in turn influenced by the TPMT genetic polymorphism and and resultant variant TPMT proteins (enzymes) which may be either higher activity or lower activity than the normal population. Higher TPMT activity leads to elevated levels of 6 methyl mercaptopurine owing to hepatotoxicity. On the other hand, lower TPMT activity leads to more production of 6 thioguanine which leads to severe myelotoxicity. According to the studies TPMT has high activity, intermediate activity, and low activity variants according to the genetic polymorphism affecting the single nucleotide mutation. TPMT with low activity leads to myelotoxicity. The other gene influencing the metabolism of azathioprine is the NUDT15 (nudix hydrolase 15) gene. NUD15 hydrolysis the 5 thioguanine triphosphate into less active 5 thioguanine monophosphate. So a decreased activity of the NUD15 gene is associated with more myelotoxicity.(4)\u0026nbsp;,(5),(6).\u0026nbsp;A meta-analysis conducted by Gennep S et al found a significantly higher thiopurine-induced leukopenia risk for TPMT with an odd ratio of 3.9 (95% CI 2.5-6.1) and for NUDT15 R139 with an odds ratio of 6.9, (95% CI 5.2-9.1). \u0026nbsp;G52A \u0026amp; 36_37ins/delGGAGTC variant carriers with odds ratios of 3.2 and 5.6 respectively also identified. A potential association between high 6-thioguanine nucleotides (6-TGN) or 6-methyl mercaptopurine (6-MMP) levels and leukopenia was also identified from the analysis.(7)\u003c/p\u003e\n\u003cp\u003eFrom the evidence generated it could be inferred that the pancytopenia in this patient was caused by the azathioprine and led to the immunosuppressed status and mucormycosis occurring and sustenance of the pancytopenia due to the effect of the drug posaconazole.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe clinical scenario of the patients gives an inference that initial azathioprine therapy possibly leads to bone marrow suppression manifested as prolonged pancytopenia especially anemia owing to immunosuppression and resulted in mucormycosis. But even after starting the specific treatment for mucormycosis the anaemia continued till the discharge of the patient and it was only resolved after 3 months. So, these hind two things one is the bone marrow suppression due to the azathioprine resulting in prolonged myelosuppression due to some mechanisms or the second thing to be kept in mind is that adding the Posaconazole and continuing the Posaconazole after the discharge may add on the bone marrow depression that\u0026rsquo;s why the recovery from anemia was prolonged. The association of the TPMT and NUD15 cannot be identified as the genotyping and phenotyping for the concerned gene not done in this patient. So, the take-home message of this case scenario is that using azathioprine and 6 Mercaptopurine-like drugs for the inflammatory bowel disease or any other indication ideally warrants the meticulous monitoring of the hematological parameters periodically and if possible single nucleotide genetic polymorphism of the TPMT and NUD15 can be done before initiating the therapy. This like events warrant the introduction of TPMT testing as a routine test in the susceptible population as a part of guidelines and resources for the testing TPMT should be made available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTRENGTH AND LIMITATION OF THE STUDY:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThis case report identifies the myelosuppression secondary to azathioprine therapy for a short period and leading to the mucormycosis secondary to either immunomodulation or immunosuppression in a relatively healthy individual.\u003c/li\u003e\n \u003cli\u003eThis warrants the routine use of either the periodic blood testing in resource poor centers or TPMT and NUD15 gene testing for predicting the azathioprine induced myelosuppression in the resource rich centers as a policy decision to prevent severe myelosuppression secondary to azathioprine or 6 mercaptopurine.\u003c/li\u003e\n \u003cli\u003eWe have not done the TPMT /NUD15 genotyping due to nonavailability of testing facility. So, association between the TPMT /NUD15 genotypic variant is not confirmed, it needs further investigations.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eTPMT- thiopurine methyl transferase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNUD15- nudix hydrolase 15\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCMV- Cytomegalovirus\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCE- MRI- Contrast-Enhanced Magnetic Resonance Imaging\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL AND CONSENT TO PARTICIPATE:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA waiver for ethics committee approval has been obtained from the institute due to the nature of the article being a case series All the authors confirm that the patient consent form has been obtained from this patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients for publication of this case series and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing does not apply to this article as no datasets were generated or analysed during the current study. All necessary information related to the case report has been provided in the article. Waiver from the Ethics Committee and the patient’s consent form will be provided upon reasonable request to the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there was no funding source for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORS' CONTRIBUTIONS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCase clinical scenario and adverse drug event monitored by initiated the conception of the case report. Case report written by AS, DS, SA, SB, JK, M, GK. Discussion and possible relations of the case scenario and adverse drug event inferred by AS, DS, SA, SB, JK,M,GK. Consent taken by AS and M . All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEGEMENT:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our heartfelt appreciation to Dr.Anoop Pratheesh P, Surgeon in the Government Health Services, Kerala, Dr. G. Krishnakumar, Physician and Intensivist at Dr. Govindans Hospital Thiruvananthapuram, Dr Surjith Singh Professor Pharmacology, and all the Consultants and Senior \u0026nbsp; residents and Junior residents especially Dr Akaash \u0026nbsp;of the Department of \u0026nbsp;General Medicine , Radiology department and Microbiology Department \u0026nbsp;involved in the treatment of Patient and \u0026nbsp;For supporting the writing and suggestions for their invaluable suggestions and unwavering support, which have greatly enriched the quality and depth of our study. \u003cstrong\u003e\u003cu\u003e\u003cbr\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePhilip JM, C. P, George C, Vijayan M. AZATHIOPRINE INDUCED PANCYTOPENIA-A CASE REPORT. Int J Pharm Pharm Sci. 2017 Feb 1;9(2):324. \u003c/li\u003e\n\u003cli\u003eHadda V, Pandey B, Gupta R, Goel A. Azathioprine induced pancytopenia: A serious complication. J Postgrad Med. 2009;55(2):139. \u003c/li\u003e\n\u003cli\u003eSchwab M, Sch\u0026auml;ffeler E, Marx C, Fischer C, Lang T, Behrens C, et al. Azathioprine therapy and adverse drug reactions in patients with inflammatory bowel disease: impact of thiopurine S-methyltransferase polymorphism. Pharmacogenetics. 2002 Aug;12(6):429\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eMoriyama T, Nishii R, Perez-Andreu V, Yang W, Klussmann FA, Zhao X, et al. NUDT15 polymorphisms alter thiopurine metabolism and hematopoietic toxicity. Nat Genet. 2016 Apr;48(4):367\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eYang JJ, Landier W, Yang W, Liu C, Hageman L, Cheng C, et al. Inherited \u003cem\u003eNUDT15\u003c/em\u003e Variant Is a Genetic Determinant of Mercaptopurine Intolerance in Children With Acute Lymphoblastic Leukemia. J Clin Oncol. 2015 Apr 10;33(11):1235\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eWalker GJ, Harrison JW, Heap GA, Voskuil MD, Andersen V, Anderson CA, et al. Association of Genetic Variants in \u003cem\u003eNUDT15\u003c/em\u003e With Thiopurine-Induced Myelosuppression in Patients With Inflammatory Bowel Disease. JAMA. 2019 Feb 26;321(8):773. \u003c/li\u003e\n\u003cli\u003evan Gennep S, Kont\u0026eacute; K, Meijer B, Heymans MW, D\u0026rsquo;Haens GR, L\u0026ouml;wenberg M, et al. Systematic review with meta-analysis: risk factors for thiopurine-induced leukopenia in IBD. Aliment Pharmacol Ther. 2019 Sep;50(5):484\u0026ndash;506. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Azathioprine, thiopurine methyl transferase, mucormycosis, Posaconazole","lastPublishedDoi":"10.21203/rs.3.rs-4226253/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4226253/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIt is evident from the previous literature that azathioprine an immunomodulator drug used for the pharmacotherapy of inflammatory bowel disease is prone to severe myelosuppression in the susceptible population. If TPMT genetic polymorphism is there it is related to the myelosuppression related to the drug azathioprine and it is linked with the metabolism of the azathioprine.\u003c/p\u003e \u003cp\u003eIn this case, a 46-year-old male patient after a short 20-day course of azathioprine for the inflammatory disease presented with fever and swelling of the face on evaluation pancytopenia was revealed, and later on further detailed evaluation, he was diagnosed with Mucormycosis. During the hospital stay, he was treated with Posaconazole and Amphotericin b liposomal preparation for the mucormycosis, and his WBC count remained normal, but the hemoglobin level remained low at 7.2 g/dl at the time of discharge.\u003c/p\u003e \u003cp\u003eThe Initial incidence of pancytopenia induced by the azathioprine and persistence of the anemia and thrombocytopenia may be due to the administration of the posaconazole for the mucormycosis.\u003c/p\u003e","manuscriptTitle":"Azathioprine-induced Pancytopenia Leading to Mucormycosis in a Patient - Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-13 01:49:16","doi":"10.21203/rs.3.rs-4226253/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07537cc0-951f-4683-941c-ba25293afc27","owner":[],"postedDate":"August 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-13T01:49:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-13 01:49:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4226253","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4226253","identity":"rs-4226253","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}