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+A 67-year-old woman was sent to emergency department because of fever and sore throat.
+Her medical history included ESRD with regular hemodialysis 3 times per week for 15 years, hyperuricemia and gout.
+She also had comorbidity such as dyslipidemia, hypertension, secondary hyperparathyroidism, and diabetes.
+The hemogram revealed a white blood cell count (WBC) of 700/μL, with 2% neutrophils, 94% lymphocytes and 2% monocytes, hemoglobin 11.1 g/dL, and platelet count, 131,000/μL.
+Under the impression of febrile neutropenia and acute pharyngitis, she was admitted to our hematologic ward for further survey and management.
+Broad-spectrum antibiotics with piperacillin 2 g and tazobactam 0.25 gm i.v.
+q8h had been administered and her infection sign resolved gradually.
+Upon admission, we reviewed her oral medication: glipizide 5 mg tid, saxagliptin 2.5 mg qd, fenofibrate 600 mg qd, aluminum hydroxide 324 mg tid, folic acid 5 mg qd, calcium carbonate 1000 mg tid, and febuxostat 40 mg qd.
+Besides, she also received epoetin-beta 2000 iu i.v.tiw.
+Except for febuxostat, all the other drugs had been used for more than 1 year.
+Febuxostat was administered 2½ months before admission for inadequate serum uric acid control by allopurinol 50 mg qd.
+Two weeks before febuxostat exposure, routine laboratory test revealed WBC 6000/μL and serum uric acid level 9.8 mg/dL.
+Febuxostat was discontinued thereafter due to the causal relationship of agranulocytosis cannot be excluded.
+Besides, we also surveyed viral infection and autoimmune disorder.
+There were no clinical or laboratory evidence of Epstein–Barr virus, cytomegalovirus, or human immunodeficiency virus infections; antinuclear antibody (ANA) and antiextractable nuclear antigen (anti-ENA) were both negative.
+Bone marrow examination during hospitalization showed hypocellular marrow with a marked decrease in myeloid component but no evidence of hematologic neoplasms.
+Chromosome analysis of bone marrow was normal karyotype.
+The patient denied history of radiation or chemicals exposure.
+After stopping febuxostat for 17 days, her neutropenia improved significantly (WBC 2100/μL, and neutrophil 66%), without any granulocyte colony-stimulating factor (G-CSF) support.
+After discharge, her WBC and differential count was completely normal during follow-up (Fig.1).
+This study was approved by our institutional review board.