Case Report Asacol-induced Neutropenia Resolution Without the Use of Granulocyte Colony-stimulating Factor Brian T. Fowler, MD, Tina Gupta, BA, and Muhammad Bilal, MD Abstract: We report a case of neutropenia and gram-negative septi- cemia in a 73-year-old male with ulcerative colitis. During the hospital course, medications were adjusted according to rare accounts of drug- induced neutropenia. While the substitution of propafenone for another antiarrhythmic brought about no change in the patient’s absolute neu- trophil count, the cessation of Asacol (Warner Chilcott, Rockaway, NJ) was followed by a significant improvement in the neutropenic state. In fact, this neutrophil count continued to trend upward for months following. We thereby conclude that Asacol carries the potential to induce neutropenia and that this reaction may be reversed in some patients solely by discontinuing the medication and without the aid of stimulating factors such as filgrastim. Key Words: Asacol, filgrastrim, inflammatory bowel disease, me- salamine, neutropenia A sacol (5-aminosalicylic acid) (Warner Chilcott, Rock- away, NJ) is widely used for the treatment of inflam- matory bowel disease (IBD) and is considered a safe choice. Most common side effects include mild gastrointestinal dis- turbance and headaches 1 Asacol has rarely been reported to result in severe blood dyscrasias including neutropenia. 1 We present a case of absolute neutropenia which resolved after cessation of Asacol without the administration of granulo- cyte colony-stimulating factor. Case Report A 73-year-old Caucasian male was transferred to our facility from an outlying hospital for further management of febrile neutropenia and gram-negative septicemia. His past medical history was significant for ulcerative colitis (UC), colonic histoplasmosis, atrial fibrillation, and chronic keratoderma. He originally presented to his local doctor with fever, abdominal pain, and fatigue for four days. While computed tomography (CT) scan of his abdomen was unremarkable, blood work up revealed low white blood cell (WBC) count of 0.6 thousand cells/mcL and abso- lute neutrophil count (ANC) of 180 cells/mcL, leading to admission in the local hospital (Fig.). He was started on broad-spectrum antibiotics and neutropenia work up was initiated. His active medication list included raniti- dine, omeprazole, metformin, rosiglitazone, Lantus (Sanofi-aventis, Bridgewater, NJ) levothyroxine, Asacol, warfarin, and propafenone. Propafenone was switched on admission to amiodarone given its rare association with neutropenia; however, the profound neutropenia continued to worsen. A bone marrow biopsy revealed hypocellular marrow without evidence of malignancy, fibrosis, or an infiltrative process. Flow cytometry yielded similar results. The patient was at this point transferred to our facility. Further history revealed a 13-year history of treatment with methotrexate for keratoderma. Sixteen months ago, (from presentation) the patient was diagnosed with biopsy- proven colonic histoplasmosis. The diagnosis was strongly linked to his immunocompromised status from chronic (continued next page) From the University of Tennessee Health Science Center, Memphis, TN. Reprint requests to Tina Gupta, BA, University of Tennessee Health Science Center, Memphis, TN 38163. Email: tgupta@uthsc.com/tgupta@utmem.edu Accepted December 22, 2009. Copyright © 2010 by The Southern Medical Association 0038-4348/0-2000/10300-1167 Key Points • Asacol (Warner Chilcott, Rockaway, NJ) is widely used for inflammatory bowel disease, is well toler- ated, and is generally safe. • Blood dyscrasias are a rare complication associated with the use of Asacol, and neutropenia is considered a very rare, albeit serious, complication of Asacol. • There are only a handful of case reports documenting Asacol-induced neutropenia in the literature. • Several case reports illustrating Asacol-induced neu- tropenia document the use of granulocyte colony-stim- ulating factor (G-CSF) to facilitate the rebound of neutrophil count to normal. • In our case report, we present a patient who returned to a normal neutrophil count, though more slowly, with cessation of Asacol and without the use of G-CSF. Southern Medical Journal • Volume 103, Number 11, November 2010 1167