A Case of Cerebral Venous Thrombosis in the Setting of Romiplostim Use (P02.226)

Abstract

Objective: To describe a case of CVT in the setting of Romiplostim (Nplate®) use. Background Thrombopoietin receptor agonists are currently recommended in patients with chronic refractory immune thrombocytopenic purpura (ITP). Thromboembolic events have been reported in less than 5% of individuals treated with romiplostim, and usually in the presence of known risk factors for thrombosis. Cerebral venous thrombosis (CVT) has been rarely reported in association with romiplostim use. Design/Methods: We report the case of a 40-year-old Caucasian woman with refractory ITP who had failed medical therapy as well as splenectomy and presented with headache and visual blurring. She was transferred to our institution due to concerns for idiopathic intracranial hypertension. Romiplostim was first administered in 2007 as part of a clinical trial and then weekly upon FDA approval in late 2008. Results: Her course while on therapy was complicated by wide fluctuations in her platelet count ranging from severe thrombocytopenia to thrombocytosis and was associated with clinically-significant bleeding and thromboembolic phenomena. A hypercoagulable work up had been unrevealing. On admission, magnetic resonance venogram (MRV) revealed extensive sagittal sinus and bilateral transverse sinus thrombosis. Her platelet count was 165 x109/L. She was initially managed with intravenous heparin, but given subsequent clinical worsening, mechanical thrombectomy and local alteplase administration was undertaken. Unfortunately, she developed refractory cerebral edema and elevated intracranial pressure. Conclusions: The association between romiplostim use and CVT is not well understood. Headache is the most commonly reported side-effect to romiplostim therapy, a fact that can mask the presence of CVT. We hypothesize that significant fluctuation in platelet count with rebound thrombocytosis while receiving thrombopoietin receptor agonists can increase the risk of thromboembolic events. Disclosure: Dr. George has nothing to disclose. Dr. Ahrens has nothing to disclose. Dr. Gomes has nothing to disclose.