Objective: To present a case of apomorphine induced hemolytic anemia

Background: Drug induced immune hemolytic anemia (DIIHA) is a potentially lethal adverse reaction; It has been implicated in the side effects profiles of more than 130 drugs importantly antibiotics (penicillin and cephalosporins), non-steroidal anti-inflammatory drugs, and chemotherapeutic agents(1). A few cases of immune hemolytic anemia caused by levodopa, and dopa-agonists have previously been reported. Hereby we are presenting a case of apomorphine induced immune hemolytic anemia.

Method: Case report.

Results: A 62-year-old man who was diagnosed with Parkinson disease since 10 years, was admitted to the ER with decreased level of consciousness that had evolved over 2 days. He had stopped taking antiparkinsonian medications since 10 days due to hallucinations and agitation that his care givers attributed to levodopa intake. On the initial evaluation, he was febrile, confused and had generalized severe rigidity, with a high serum CPK level. A diagnosis of neuroleptic malignant syndrome was made and in addition to adequate hydration, an NG tube was placed, and he was started on bromocriptine and levodopa. After 72 hours of therapy, his fever resolved, and CPK levels decreased; but his rigidity persisted. A subcutaneous apomorphine pump was inserted and the dose was titrated on 1.3 mg/h continuous infusion. The initial response to apomorphine was favorable but after two days of therapy, the patient developed immune hemolytic anemia (Hb: 6.7g/dl, MCV: 79 ff, LDH: 1500 UI/dl, total bilirubin 2.4mg/dl, direct bilirubin 0.7mg/dl, and a positive coombs test at 37°C). After discontinuation of apomorphine, anemia improved (Hb: 11.3mg/dl) and he was discharged on levodopa.

Conclusion: Drugs can cause hemolytic anemia by three different mechanisms; inducing oxidative stress, thrombotic microangiopathy, and by activating immune mechanisms. DIIHA has first been reported in 1972 as a complication of Levodopa(2). It has also been reported as a complication of dopamine agonists including cabergoline and apomorphine(3,4). Since the “Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson’s disease” in 2015(5), we are presenting the second documented case of apomorphine induced immune hemolytic anemia.

References: 1. Ashkenazi R, Ben-Shachar D, Youdim MB. Nutritional iron and dopamine binding sites in the rat brain. Pharmacol Biochem Behav [Internet]. 1982 [cited 2017 Apr 4];17 Suppl 1:43–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7184034 2. Clark LS. Autoimmune hemolytic anemia in relation to L-dopa therapy. Am J Med Technol [Internet]. 1972 Jan [cited 2019 Mar 1];38(1):9–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/5008030 3. Gürbüz F, Yağcı-Küpeli B, Kör Y, Yüksel B, Zorludemir S, Gürbüz BB, et al. The first report of cabergoline-induced immune hemolytic anemia in an adolescent with prolactinoma. J Pediatr Endocrinol Metab [Internet]. 2014 Jan 1 [cited 2019 Mar 1];27(1–2). Available from: https://www.degruyter.com/view/j/jpem.2014.27.issue-1-2/jpem-2013-0151/jpem-2013-0151.xml 4. Venegas Pérez B, Arquero Portero T, Sánchez Fernández MS, Feliz Feliz C, Del Val Fernández J, García-Ruiz PJ. Apomorphine-Induced Immune Hemolytic Anemia. Mov Disord Clin Pract [Internet]. Wiley-Blackwell; 2017 [cited 2019 Feb 28];4(1):145–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30713961 5. Trenkwalder C, Chaudhuri KR, García Ruiz PJ, LeWitt P, Katzenschlager R, Sixel-Döring F, et al. Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson’s disease – Clinical practice recommendations. Parkinsonism Relat Disord [Internet]. 2015 Sep [cited 2019 Mar 1];21(9):1023–30. Available from: https://linkinghub.elsevier.com/retrieve/pii/S135380201500262X

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MDS Abstracts - https://www.mdsabstracts.org/abstract/apomorphine-induced-hemolytic-anemia-a-case-report-and-literature-review/