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257 To the Editor We would like to present a case involving a 19‐year‐old man with bone marrow suppression and preliminary diagnosis of plas‐ ma cell leukemia after metamizole overuse. Pri‐ or to this diagnosis, our patient was healthy and did not use any medication on a regular basis. However, he recently suffered from a toothache and took from 0.5 to 2 g/d of metamizole for 3 weeks. After this time, he observed severe sore throat, cough, fever, and muscle aches. He con‐ tinued metamizole but this time in combination with ibuprofen (400–600 mg/d). A week later, the symptoms deteriorated and a general practi‐ tioner prescribed him azithromycin, followed by cefuroxime, both without improvement. Final‐ ly, after 5 weeks of overuse of nonsteroidal anti‐ ‐inflammatory drugs, our patient was admitted to the hospital for further diagnostic evaluation and treatment. On admission to the hospital, fever, tachycar‐ dia, palpable and painful peripheral lymph nodes, enlarged tonsils with purulent plugs, multiple aphthae on the oral mucosa, and dental caries were observed. Laboratory tests showed leuco‐ penia (1100/μl) and lymphopenia (900/μl) with normal hemoglobin levels and platelet count, and high levels of inflammatory markers (C‐reactive protein, 255.7 mg/l; procalcitonin, 1.79 ng/ml). During hospitalization, red and white blood cell counts lowered and were accompanied by liver damage and prolonged thrombin and prothrom‐ bin time. Uncommon viral (hepatitis B virus, hep‐ atitis C virus, human immunodeficiency virus, cytomegalovirus, Epstein‐Barr virus) and syph‐ ilis infections as well as autoimmune diseases were excluded. All microbiological tests, includ‐ ing blood urine and throat swab cultures, were negative. Bone marrow aspiration revealed iso‐ lated granulocyte aplasia with plasma cells con‐ stituting 30% of the cells. The patient was trans‐ ferred to the Hematology Unit with suspicion of plasma cell leukemia. The patient was initially in good condition but showed radiologic signs of pneumonia and maxillary sinusitis. He was referred to a dentist who removed all caries in teeth, but despite us‐ ing wide‐spectrum empiric antibiotics (ceftazi‐ dime, clarithromycin, meropenem, and vanco‐ mycin) his clinical condition worsened and blood pancytopenia developed. A bone marrow biopsy showed suppression of all lines with 35% of reac‐ tive plasma cells (FIGURE 1A), while in blood smears only single plasma cells were present (FIGURE 1B). These findings suggested inflammatory or reac‐ tive etiology of the pathology. Active tuberculosis of the bone marrow was also excluded but the se‐ rologic blood test showed elevated levels of par‐ vovirus B19‐specific IgM antibodies. We admin‐ istered granulocyte colony‐stimulating factor for 5 days, but leukopenia persisted. For this reason, a second bone marrow biopsy was performed, which demonstrated bone marrow regeneration but with signs of macrophage activation and he‐ mophagocytosis (FIGURE 1C). This finding was con‐ sistent with the laboratory characteristics of liv‐ er damage and coagulation abnormalities. Macro‐ phage activation syndrome (MAS) was diagnosed and corticosteroids were prescribed (dexameth‐ asone 3 × 8 mg/d for 5 days, followed by predni‐ sone 1 mg/kg/d). This resulted in a rapid clinical and laboratory improvement. A week later, bone marrow aspirate was normal. Systemic steroids were tampered for the next 3 weeks and final‐ ly stopped. Four weeks after discharge, the pa‐ tient was healthy, did not take any medications, and his laboratory results were normal (includ‐ ing blood cell counts and inflammatory markers). The most likely cause of bone marrow suppres‐ sion in our patient was the metamizole abuse be‐ cause this medication had been taken for 5 weeks (with about 30 g of cumulative dose). Metamizole is a commonly used nonsteroidal anti‐inflamma‐ tory drug that is prohibited in many countries due to the risk of agranulocytosis. In Poland, it is still available without prescription. A national safety LETTER TO THE EDITOR

Bone marrow suppression with plasma cell leukemia‑like reaction complicated by macrophage activation syndrome after metamizole overuse