Argatroban therapy for heparin-induced thrombocytopenia in a patient with coronavirus disease 2019
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LETTER TO THE EDITOR
Argatroban therapy for heparin-induced thrombocytopenia in a patient with coronavirus disease 2019 Yoshihiko Ogawa1 · Toshihiko Nagata2 · Taisuke Akiyama2 · Koji Nishida3 · Junji Kumasawa2 · Michihiko Kohno2 · Hisakazu Kohata2 · Iwao Gohma3 Accepted: 6 August 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
To the editor, Coronavirus disease 2019 (COVID-19) can lead to systemic coagulation activation and thrombotic complications. Therefore, heparin treatment has been recommended for COVID-19 [1]. One study showed that heparin treatment appeared to be associated with better prognosis in patients with severe COVID-19 with markedly elevated D-dimer levels [2]. However, the incidence of venous thromboembolism (VTE) is high with routine thromboprophylaxis [3]. Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies that bind to complexes of platelet factor 4 and heparin (PF4/ heparin antibody complex). It is recognized that anti-PF 4/ heparin antibodies commonly develop after heparin exposure [4]. We present a case of acute pulmonary thrombosis due to COVID-19 for which veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy was administered, and thrombocytopenia that developed with PF4/heparin antibody formation. The patient was successfully treated with low dosage introduction of argatroban. A 37-year-old man was admitted to our hospital with dyspnea. Eight days before admission, he developed a persistent fever and a loss of taste. Three days before admission, a polymerase chain reaction (PCR) test result for SARSCoV-2 at a nearby hospital was positive. Soon after entering a quarantine accommodation facility, he experienced dyspnea and was transferred to our hospital.
* Yoshihiko Ogawa [email protected] 1
Department of Infectious Diseases, Sakai City Medical Center, Ebaraji 1‑1‑1, Sakai, Osaka 593‑8304, Japan
2
Department of Critical Care Medicine, Sakai City Medical Center, Ebaraji 1‑1‑1, Sakai, Osaka 593‑8304, Japan
3
Department of Respiratory Medicine, Sakai City Medical Center, Ebaraji 1‑1‑1, Sakai, Osaka 593‑8304, Japan
At admission, he was 175 cm in height and weighed 110 kg (body mass index: 35.9). He had no reported medical history. His body temperature was 39.2 °C. He required 3 L/ minute of oxygen therapy. Oral favipiravir and ciclesonide (inhalation route) were introduced to treat COVID-19. Blood examination revealed elevated levels of AST (63 IU/L), ALT (43 IU/L), LDH (700 IU/L), and CRP (3.28 mg/dL). The D-dimer level was 1.62 µg/mL. Chest X-ray showed diffuse bilateral ground glass opacities (Fig. 1a). On day 3 after admission, blood examination revealed acutely elevated D-dimer (13.721 µg/mL), without findings suggestive of VTE, such as Homan’s sign or lower limb grasp pain. His dyspnea had improved since admission. Thus, we introduced prophylactic intravenous unfractionated heparin therapy (5000 IU bolus and 300 IU/h initially), and the dosage was adjusted according to th
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