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Heparin-induced thrombocytopenia and lack of efficacy: case report A case series of two patients described a 69-year-old woman, who developed heparin-induced thrombocytopenia during anticoagulation treatment with heparin and enoxaparin sodium for hypercoagulability. Additionally, she exhibited lack of efficacy during treatment with heparin and enoxaparin sodium [routes and dosages not stated] The woman, who had history of anxiety, asthma, breast cancer and morbid obesity, presented to the emergency department on 6 April 2020 with worsening dyspnoea. She was intubated for impending respiratory compromise and transferred to the ICU. On 8 april 2020, her COVID-19 test came back positive. Therefore, she started receiving off-label treatment with hydroxychloroquine and azithromycin. For increased interleukin-6 levels, she received off-label treatment with one dose of tocilizumab. Additionally, she started receiving methylprednisolone [solumedrol] due to concerns for possible asthma exacerbation. On 16 April 2020, she developed pneumothorax. On 18 April 2020, she was extubated and transferred to intermediate care unit (IU) for further management. Given the increase in inflammatory markers and hypercoagulable state, she started receiving a full-dose anticoagulation with heparin. She appeared to be stable on non-invasive ventilation and unspecified anxiolytics. On 21 April 2020, she was re-intubated for respiratory failure. Chest x-ray suggested an effusion. However, after drainage by chest tube, it was found to be haemothorax. Heparin-induced thrombocytopenia was suspected. Therefore, heparin therapy was switched to intermediate dose enoxaparin sodium [lovenox]. Subsequently, the woman was treated with two units of blood and intermittent vasopressor support. After successful resolution of haemothorax, she was successfully extubated on 23 April 2020 to nasal cannula and transferred to IU. However, thrombocytopenia continued to worsen on 30 April 2020 with platelets of 22000 and D-dimer >20000. CT angiography revealed bilateral segmental pulmonary emboli despite ongoing anticoagulation therapy. Enoxaparin sodium was stopped due to concern for second episode of heparin-induced thrombocytopenia. She tested positive for heparin PF4 antibody. Thereafter, she was started on argatroban. Later, she received plasmapheresis. She continued to be critically ill [outcome not stated]. Turshudzhyan A. SARS-CoV2 induced pulmonary embolism and complications from anticoagulation. Respiratory Medicine Case Reports 31: 2020. Available from: URL: 803498314 http://doi.org/10.1016/j.rmcr.2020.101176

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Reactions 29 Aug 2020 No. 1819