A combination drug consisting of chlordiazepoxide hydrochloride and clidinium bromide (Librax) is frequently prescribed for irritable bowel disease, as it combines the antianxiety action of chlordiazepoxide and the anticholinergic and spasmolytic effects of clidinium. We report a case of acute thrombocytopenic purpura that developed during chlordiazepoxide-clidinium therapy.
A 68-year-old man was admitted for rhinorrhagia and generalized petechiae. He had been receiving lorazepam, perphenazine, and amitriptyline hydrochloride for many years. Two months before his admission, chlordiazepoxide hydrocloride–clidinium bromide was prescribed at a dosage of 5 mg of chlordiazepoxide and 2.5 mg of clindinium 3 times per day for irritable bowel disease. On admission, his spleen was not palpable. A peripheral blood sample revealed a low platelet count (15 × 103/µL). The total white blood cell count, leukocyte differential cell count, and hemoglobin level were normal. The fibrinogen concentration, prothrombin time, and partial thromboplastin time were also normal. A bone marrow aspirate showed an increased number of megakaryocytes. An extensive workup for exclusion of infections was done. Serological tests were negative for cytomegalovirus, Epstein-Barr virus, human immunodeficiency virus, Mycoplasma, and Toxoplasma. Tests were also negative for antinuclear antibodies, antiplatelet IgG antibodies by a rapid solid-phase indicator red cell assay, and antibodies to glycoprotein IIb-IIIa by a solid-phase competitive enzyme-linked immunosorbent assay. The chlordiazepoxide-clidinium therapy was considered a possible cause of the syndrome and was discontinued. The patient continued to receive the other medications. Prednisolone (1mg/kg) was administered intravenously. The clinical manifestations and thrombocytopenia resolved in a few days, and the steroid therapy was uneventfully tapered off in the following 2 weeks.