Agranulocytosis in Bangkok, Thailand: A predominantly drug-induced diseasewith an unusually low incidence

Agranulocytosis, a syndrome characterized by a marked reduction in circulat ing granulocytes, is strongly associated with medical drug use in Europe an d the United States. Unregulated use of common pharmaceutical agents in dev eloping countries has been suspected of causing large numbers of cases of a granulocytosis and deaths, especially among children. To elucidate the inci dence and etiology of agranulocytosis in Thailand, a population-based case- control study of symptomatic agranulocytosis that resulted in hospital admi ssion was conducted in Bangkok from 1990 to 1994. An attempt was also made to study the disease in Khonkaen tin northeastern Thailand) and Songkla tin southern Thailand), but there were insufficient cases in the latter region s, and the analysis was confined to subjects from Bangkok. In that region, the overall incidence of agranulocytosis was 0.8 per million per year; ther e were no deaths. As expected, the incidence was higher in females (0.9 per million), and it increased with age (4.3 per million beyond age 60). Among 25 cases and 529 controls the relative risk estimate for a combined catego ry of all suspect drugs was 9.2 (95% confidence interval = 3.9-21), and the proportion of cases that could be attributed to drug use was 68%. For indi vidual drugs and drug classes the data were sparse; within these Limitation s, the strongest association appeared to be with antithyroid drugs. One cas e and three controls were exposed to dipyrone, a drug known to cause agranu locytosis; with such scanty data the risk could not be evaluated. Exposure to pesticides or solvents was not associated with an increased risk. This i s the first formal epidemiologic study of agranulocytosis in a developing c ountry. As in the West, most cases are attributable to medical drug use. Ho wever, the incidence of agranulocytosis in Bangkok, and apparently, in Thai land as a whole, is unusually low, and the disease does not pose a public h ealth risk.