Methylphenidate and leukopenia?

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Penguin10

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I'm an NP at an FQHC. I recently saw an 18 year old male with a one year history of atraumatic back pain. Otherwise happy and healthy. PMH significant for asthma and ADHD. Meds include methylphenidate 20 mg daily (at this point I'm not clear on the exact form).

I was concerned by the history got labs and order x-ray. His WBC is about 2.5 and ANC 570. Obviously, there's a differential for leukopenia which I'm pursuing, but in reviewing his meds I was surprised to see leukopenia as a possible adverse effect from methylphenidate.

Is this something you all see often? To what degree?

Appreciate any comments/experiences.
 
I'm an NP at an FQHC. I recently saw an 18 year old male with a one year history of atraumatic back pain. Otherwise happy and healthy. PMH significant for asthma and ADHD. Meds include methylphenidate 20 mg daily (at this point I'm not clear on the exact form).

I was concerned by the history got labs and order x-ray. His WBC is about 2.5 and ANC 570. Obviously, there's a differential for leukopenia which I'm pursuing, but in reviewing his meds I was surprised to see leukopenia as a possible adverse effect from methylphenidate.

Is this something you all see often? To what degree?

Appreciate any comments/experiences.
It would be very unusual.
 
Relevant questions:

* How long has he been on the methylphenidate?
* Any recent infectious symptoms?
* Weight?
* Ethnicity?
* Any other cytopenias?

Thanks for all the responses.

-Don't know how long he's been taking methylphenidate. Is shorter or longer exposure more likely relevant (longer I guess)?
-No recent infections.
-65 kg, BMI 21. How does this impact?
-African-American
-No other cytopenias. H&H 15 & 45, RBC slightly elevated 5.9 (5.8 uln for our lab), plts 243. MCV was slightly low at 77 (lln 79). Ferritin 56, B12 647, they couldn't add on a copper.

He isn't aware of a family history of blood count abnormalities and hasn't had prior labs that he can recall. I was hoping BEN and not some kind of badness, but the hematologist who looked at his labs for me was concerned because the ANC was around 500, which is apparently lower than where most BEN folks live.
 
What was discouraging about the physical exam or other historical points that prompted you to order labs on top of plain films? Not febrile I'm assuming? Also, ANC has a diurnal variation. I would first recheck labs in the morning. Once you rule out the big things let heme make the call whether this is BEN, drug induced (2 case reports in the literature- I seriously doubt it's that), or some other blood disorder.
 
Thanks for all the responses.

-Don't know how long he's been taking methylphenidate. Is shorter or longer exposure more likely relevant (longer I guess)?
-No recent infections.
-65 kg, BMI 21. How does this impact?
-African-American
-No other cytopenias. H&H 15 & 45, RBC slightly elevated 5.9 (5.8 uln for our lab), plts 243. MCV was slightly low at 77 (lln 79). Ferritin 56, B12 647, they couldn't add on a copper.

He isn't aware of a family history of blood count abnormalities and hasn't had prior labs that he can recall. I was hoping BEN and not some kind of badness, but the hematologist who looked at his labs for me was concerned because the ANC was around 500, which is apparently lower than where most BEN folks live.
- If > 3 months, unlikely the cause of the neutropenia.
- Could still be an acute viral episode, but less likely postinfectious.
- A roundabout way of getting at nutritional deficiency (e.g. from appetite suppression from the methylphenidate)
- I believe AA falls under groups where it may just be benign ethnic but agreed it does seem lower than would be expected for BEN.
 
Once you rule out the big things let heme make the call whether this is BEN, drug induced (2 case reports in the literature- I seriously doubt it's that), or some other blood disorder.
Agree with this. Methylphenidate-induced leukopenia is a diagnosis that should be arrived after a specialist physician has ruled out everything else.

Did you ever determine why an 18 year old is having a year of atraumatic back pain?
 
Anything can do anything, so I never discount the possibility if the factors seem logical. I've seen some weird things happen. However, MPH would not be my first guess as causative but eliminating it as a possibility is certainly an easy thing to do and very low risk.
 
Agree with the sentiments above. If it's been reported, I would stop the methylphenidate anyway. 20mg of ritalin isn't needed for anyone. If it is the cause, then not removing it could result in very bad outcome.

But what everyone else is responding to is the need to find the actual diagnosis, which is still unlikely to be methylphenidate and should not be approached differently just because you stopped methylphenidate.
 
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