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and treatment was started with acitretin &#40;Acitretina IFC&#44; 25<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#46; The follow-up analysis performed 6 weeks later revealed a platelet count of 6000&#47;&#956;L &#40;previous&#44; 177&#160;000&#47;&#956;L&#41;&#46; The remaining results were normal &#40;hemoglobin&#44; 15&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#59; leukocytes&#44; 7900&#47;&#956;L&#41;&#46; The patient was asymptomatic&#44; with no bleeding&#44; fever&#44; or other manifestations&#46; A complete blood workup &#40;clotting&#44; biochemistry &#91;kidney profile&#44; liver profile with lactate dehydrogenase&#93;&#44; antinuclear antibodies&#44; anti-DNA antibodies&#44; lupus anticoagulant&#44; anticardiolipin antibodies&#44; complement&#44; electrophoresis&#44; immunoglobulins&#44; thyroid hormones&#44; vitamin B<span class="elsevierStyleInf">12</span>&#44; folic acid&#44; and serology &#91;hepatitis B and C&#44; human immunodeficiency virus&#93;&#41; was performed to rule out possible causes of thrombocytopenia&#46; The results were normal&#46; Abdominal ultrasound revealed fatty liver disease with no splenomegaly&#46; Specialists from the hematology department decided to suspend acitretin as a potential cause&#44; since it had been started only a short time previously&#46; Fenofibrate was maintained&#44; and intravenous immunoglobulin was started &#40;0&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg in 3 doses&#41;&#44; as was methylprednisolone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; tapering dose&#41;&#46; The platelet count returned to normal 4 weeks later &#40;226&#46;000&#47;&#956;L&#41;&#46; The skin lesions were treated with topical corticosteroids&#46; The complete blood count remained unaltered 6 months later&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Acitretin is a second-generation monoaromatic retinoid&#46; It is an active metabolite of its precursor&#44; etretinate&#44; and has been marketed since 1997&#46; Acitretin is indicated for severe psoriasis&#44; pustular psoriasis&#44; congenital ichthyosis and ichthyosiform disorders&#44; cutaneous and mucous lichen planus&#44; and severe disorders with dyskeratosis and&#47;or hyperkeratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It has an antiproliferative effect on psoriatic plaques&#44; reducing thickness&#44; erythema&#44; and desquamation&#46; It also has an anti-inflammatory effect&#46; Given that its pharmacokinetics&#44; effectiveness&#44; and adverse reactions vary from person to person&#44; the dose must be selected on an individual basis&#44; with every attempt made to reach a minimum efficacious dose&#46; Like all retinoids&#44; it is teratogenic&#44; and most adverse effects are dose-dependent and reversible&#46; The most frequent are mucocutaneous effects and lipid and hepatic abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The Summary of Product Characteristics of Neotigason and that of Acitretina IFC do not mention hematologic abnormalities&#44; and a review of the literature reveals few cases&#46; In fact&#44; no cases of thrombocytopenia induced by acitretin have been reported&#44; although 3 cases caused by etretinate &#40;10-50<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; have been described in psoriasis patients between 15 days and 2 months after initiation of treatment<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a>&#59; the platelet count fell to 2000 in one of the cases and took more than 2 years to return to normal&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the remaining cases&#44; values took weeks to return to normal&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> The Summary of Product Characteristics of isotretinoin reports anemia&#44; thrombocytopenia&#44; thrombocytosis&#44; and neutropenia as common adverse effects&#46; The literature contains 5 case reports of thrombocytopenia that appeared between a few days and up to 6 months after initiation of isotretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Diagnosis of the cases of retinoid-induced thrombocytopenia was based on symptoms once other causes had been ruled out&#46; Other reported hematologic abnormalities include acitretin-induced agranulocytosis &#40;1 case&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> neutropenia &#40;2 cases&#41;&#44; and isotretinoin-induced agranulocytosis &#40;2 cases&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Furthermore&#44; there has also been a report of a case of paroxysmal nocturnal hemoglobinuria and another of anemia caused by vitamin B<span class="elsevierStyleInf">12</span> and folic acid deficiency induced by isotretinoin&#46; In the case of bexarotene and alitretinoin&#44; the Summary of Product Characteristics reports hematologic abnormalities&#46; Leukopenia&#44; mainly neutropenia&#44; is common with bexarotene&#44; although platelet abnormalities are unusual&#59; thrombocytosis is common with alitretinoin&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The mechanisms underlying drug-induced thrombocytopenia fall into 2 categories&#58; suppression of platelet production in bone marrow and increased destruction or clearance of platelets in peripheral blood&#46; The first is accompanied by pancytopenia&#44; is usually caused by chemotherapy&#44; and is dose-dependent&#46; The second mechanism is divided into 3 subtypes&#58; the nonimmune subtype&#44; in which the drug has a toxic effect on platelets&#59; the immune subtype&#44; which is caused by drug-specific antibodies that bind to the platelets and is responsible for most cases of drug-induced thrombocytopenia&#59; and the autoimmune subtype&#44; in which antibodies are not drug-dependent&#46; The most frequently involved drugs are quinine and trimethoprim-sulfamethoxazole&#44; although vancomycin&#44; anti-inflammatory drugs&#44; anticonvulsive agents&#44; diuretics&#44; and tuberculostatic drugs also play a role&#46; The incidence of drug-induced thrombocytopenia is around 0&#46;6-1&#46;6 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 person-years&#44; although this figure may be underestimated&#46; The condition should be suspected mainly in polymedicated hospitalized adults with severe acute thrombocytopenia &#40;generally &#60;10<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;L&#41;&#46; Drug-induced thrombocytopenia usually appears 1 to 2 weeks after initiation of therapy&#44; and recurrences are observed early after reintroduction&#46; Patients usually present petechiae&#44; purpura&#44; hematomas&#44; mucosal bleeding&#44; and a risk of internal bleeding &#40;including brain hemorrhage&#41;&#46; The condition can also be fatal&#46; Diagnosis is based on clinical findings&#44; depending on the temporal relationship between initiation of drug therapy and onset of thrombocytopenia and after ruling out other causes &#40;infection &#91;mainly viral&#93;&#44; vaccination&#44; pregnancy&#44; lymphoproliferative diseases&#44; autoimmune diseases&#44; and idiopathic thrombocytopenic purpura&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The ideal approach would be to demonstrate the presence of specific antiplatelet antibodies&#59; however&#44; the relevant tests are not usually available and are not performed as part of daily clinical practice&#46; The platelet count recovers 1 to 2 weeks after the culprit drug has been withdrawn&#59; in severe cases&#44; corticosteroids&#44; immunoglobulins&#44; and even platelet transfusions are necessary&#46; In patients with drug-induced thrombocytopenia&#44; corticosteroids can be withdrawn quickly after the platelet count recovers&#59; in idiopathic thrombocytopenic purpura&#44; however&#44; the course of treatment is longer&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In the case we report&#44; thrombocytopenia resolved quickly after withdrawal of acitretin and treatment with corticosteroids and immunoglobulins&#46; Given the clear temporal relationship and clinical course after withdrawal of acitretin&#44; we decided not to readminister the potential culprit drug to confirm the diagnosis&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Arpa M&#44; L&#243;pez-Nieto M&#44; Santiago S&#225;nchez-Mateos JL&#44; S&#225;nchez-Caminero MP&#46; Trombocitopenia en probable relaci&#243;n con acitretina&#46; 2015&#59;106&#58;692&#8211;693&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Chong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initiation of the suspect drug before onset of thrombocytopenia and normalization of the platelet count after withdrawal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The suspect drug is the only one administered before onset of thrombocytopenia or other drugs are continued or reintroduced after withdrawal of the suspect drug&#44; with no changes in the platelet count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other causes of thrombocytopenia are ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reintroduction of the suspect drug induces recurrence of thrombocytopenia or thrombocytopenia is detected in laboratory tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Level of Evidence</span><span class="elsevierStyleHsp" style=""></span>Definitive&#58; Criteria 1&#44; 2&#44; 3&#44; and 4<span class="elsevierStyleHsp" style=""></span>Probable&#58; Criteria 1&#44; 2&#44; and 3<span class="elsevierStyleHsp" style=""></span>Possible&#58; Criterion 1<span class="elsevierStyleHsp" style=""></span>Improbable&#58; Absence of criterion 1&nbsp;\t\t\t\t\t\t\n
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Case and Research Letters
Thrombocytopenia Probably Induced by Acitretin
Trombocitopenia en probable relación con acitretina
M. García-Arpa
Autor para correspondencia
mgarciaa73@yahoo.es

Corresponding author.
, M. López-Nieto, J.L. Santiago Sánchez-Mateos, M.P. Sánchez-Caminero
Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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    "titulo" => "Thrombocytopenia Probably Induced by Acitretin"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Retinoids are nonsteroidal hormonal compounds related to retinol&#46; They were discovered more than 50 years ago and have various biologic effects&#46; The oral retinoids currently used in dermatology have different indications and include isotretinoin&#44; acitretin&#44; bexarotene&#44; and alitretinoin&#46; We present the case of a patient who developed thrombocytopenia that was probably induced by acitretin&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 78-year-old man with hypertriglyceridemia that had been controlled with fenofibrate for the previous 5 months&#46; He consulted with lesions on the hands that had appeared with a burning sensation 8 months previously&#46; Physical examination revealed delimited hyperkeratotic plaques on the palms and dorsum with nail pitting&#46; He was diagnosed with psoriasis&#46; The results of a complete blood count and biochemistry were normal&#44; and treatment was started with acitretin &#40;Acitretina IFC&#44; 25<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#46; The follow-up analysis performed 6 weeks later revealed a platelet count of 6000&#47;&#956;L &#40;previous&#44; 177&#160;000&#47;&#956;L&#41;&#46; The remaining results were normal &#40;hemoglobin&#44; 15&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#59; leukocytes&#44; 7900&#47;&#956;L&#41;&#46; The patient was asymptomatic&#44; with no bleeding&#44; fever&#44; or other manifestations&#46; A complete blood workup &#40;clotting&#44; biochemistry &#91;kidney profile&#44; liver profile with lactate dehydrogenase&#93;&#44; antinuclear antibodies&#44; anti-DNA antibodies&#44; lupus anticoagulant&#44; anticardiolipin antibodies&#44; complement&#44; electrophoresis&#44; immunoglobulins&#44; thyroid hormones&#44; vitamin B<span class="elsevierStyleInf">12</span>&#44; folic acid&#44; and serology &#91;hepatitis B and C&#44; human immunodeficiency virus&#93;&#41; was performed to rule out possible causes of thrombocytopenia&#46; The results were normal&#46; Abdominal ultrasound revealed fatty liver disease with no splenomegaly&#46; Specialists from the hematology department decided to suspend acitretin as a potential cause&#44; since it had been started only a short time previously&#46; Fenofibrate was maintained&#44; and intravenous immunoglobulin was started &#40;0&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg in 3 doses&#41;&#44; as was methylprednisolone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; tapering dose&#41;&#46; The platelet count returned to normal 4 weeks later &#40;226&#46;000&#47;&#956;L&#41;&#46; The skin lesions were treated with topical corticosteroids&#46; The complete blood count remained unaltered 6 months later&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Acitretin is a second-generation monoaromatic retinoid&#46; It is an active metabolite of its precursor&#44; etretinate&#44; and has been marketed since 1997&#46; Acitretin is indicated for severe psoriasis&#44; pustular psoriasis&#44; congenital ichthyosis and ichthyosiform disorders&#44; cutaneous and mucous lichen planus&#44; and severe disorders with dyskeratosis and&#47;or hyperkeratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It has an antiproliferative effect on psoriatic plaques&#44; reducing thickness&#44; erythema&#44; and desquamation&#46; It also has an anti-inflammatory effect&#46; Given that its pharmacokinetics&#44; effectiveness&#44; and adverse reactions vary from person to person&#44; the dose must be selected on an individual basis&#44; with every attempt made to reach a minimum efficacious dose&#46; Like all retinoids&#44; it is teratogenic&#44; and most adverse effects are dose-dependent and reversible&#46; The most frequent are mucocutaneous effects and lipid and hepatic abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The Summary of Product Characteristics of Neotigason and that of Acitretina IFC do not mention hematologic abnormalities&#44; and a review of the literature reveals few cases&#46; In fact&#44; no cases of thrombocytopenia induced by acitretin have been reported&#44; although 3 cases caused by etretinate &#40;10-50<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; have been described in psoriasis patients between 15 days and 2 months after initiation of treatment<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a>&#59; the platelet count fell to 2000 in one of the cases and took more than 2 years to return to normal&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the remaining cases&#44; values took weeks to return to normal&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> The Summary of Product Characteristics of isotretinoin reports anemia&#44; thrombocytopenia&#44; thrombocytosis&#44; and neutropenia as common adverse effects&#46; The literature contains 5 case reports of thrombocytopenia that appeared between a few days and up to 6 months after initiation of isotretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Diagnosis of the cases of retinoid-induced thrombocytopenia was based on symptoms once other causes had been ruled out&#46; Other reported hematologic abnormalities include acitretin-induced agranulocytosis &#40;1 case&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> neutropenia &#40;2 cases&#41;&#44; and isotretinoin-induced agranulocytosis &#40;2 cases&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Furthermore&#44; there has also been a report of a case of paroxysmal nocturnal hemoglobinuria and another of anemia caused by vitamin B<span class="elsevierStyleInf">12</span> and folic acid deficiency induced by isotretinoin&#46; In the case of bexarotene and alitretinoin&#44; the Summary of Product Characteristics reports hematologic abnormalities&#46; Leukopenia&#44; mainly neutropenia&#44; is common with bexarotene&#44; although platelet abnormalities are unusual&#59; thrombocytosis is common with alitretinoin&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The mechanisms underlying drug-induced thrombocytopenia fall into 2 categories&#58; suppression of platelet production in bone marrow and increased destruction or clearance of platelets in peripheral blood&#46; The first is accompanied by pancytopenia&#44; is usually caused by chemotherapy&#44; and is dose-dependent&#46; The second mechanism is divided into 3 subtypes&#58; the nonimmune subtype&#44; in which the drug has a toxic effect on platelets&#59; the immune subtype&#44; which is caused by drug-specific antibodies that bind to the platelets and is responsible for most cases of drug-induced thrombocytopenia&#59; and the autoimmune subtype&#44; in which antibodies are not drug-dependent&#46; The most frequently involved drugs are quinine and trimethoprim-sulfamethoxazole&#44; although vancomycin&#44; anti-inflammatory drugs&#44; anticonvulsive agents&#44; diuretics&#44; and tuberculostatic drugs also play a role&#46; The incidence of drug-induced thrombocytopenia is around 0&#46;6-1&#46;6 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 person-years&#44; although this figure may be underestimated&#46; The condition should be suspected mainly in polymedicated hospitalized adults with severe acute thrombocytopenia &#40;generally &#60;10<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;L&#41;&#46; Drug-induced thrombocytopenia usually appears 1 to 2 weeks after initiation of therapy&#44; and recurrences are observed early after reintroduction&#46; Patients usually present petechiae&#44; purpura&#44; hematomas&#44; mucosal bleeding&#44; and a risk of internal bleeding &#40;including brain hemorrhage&#41;&#46; The condition can also be fatal&#46; Diagnosis is based on clinical findings&#44; depending on the temporal relationship between initiation of drug therapy and onset of thrombocytopenia and after ruling out other causes &#40;infection &#91;mainly viral&#93;&#44; vaccination&#44; pregnancy&#44; lymphoproliferative diseases&#44; autoimmune diseases&#44; and idiopathic thrombocytopenic purpura&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The ideal approach would be to demonstrate the presence of specific antiplatelet antibodies&#59; however&#44; the relevant tests are not usually available and are not performed as part of daily clinical practice&#46; The platelet count recovers 1 to 2 weeks after the culprit drug has been withdrawn&#59; in severe cases&#44; corticosteroids&#44; immunoglobulins&#44; and even platelet transfusions are necessary&#46; In patients with drug-induced thrombocytopenia&#44; corticosteroids can be withdrawn quickly after the platelet count recovers&#59; in idiopathic thrombocytopenic purpura&#44; however&#44; the course of treatment is longer&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In the case we report&#44; thrombocytopenia resolved quickly after withdrawal of acitretin and treatment with corticosteroids and immunoglobulins&#46; Given the clear temporal relationship and clinical course after withdrawal of acitretin&#44; we decided not to readminister the potential culprit drug to confirm the diagnosis&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Chong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initiation of the suspect drug before onset of thrombocytopenia and normalization of the platelet count after withdrawal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The suspect drug is the only one administered before onset of thrombocytopenia or other drugs are continued or reintroduced after withdrawal of the suspect drug&#44; with no changes in the platelet count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other causes of thrombocytopenia are ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reintroduction of the suspect drug induces recurrence of thrombocytopenia or thrombocytopenia is detected in laboratory tests&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Level of Evidence</span><span class="elsevierStyleHsp" style=""></span>Definitive&#58; Criteria 1&#44; 2&#44; 3&#44; and 4<span class="elsevierStyleHsp" style=""></span>Probable&#58; Criteria 1&#44; 2&#44; and 3<span class="elsevierStyleHsp" style=""></span>Possible&#58; Criterion 1<span class="elsevierStyleHsp" style=""></span>Improbable&#58; Absence of criterion 1&nbsp;\t\t\t\t\t\t\n
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