Heparin
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Heparin Autoimmune heparin-induced thrombocytopenia: case report
An 86-year-old man developed autoimmune heparin-induced thrombocytopenia following treatment with heparin [route not stated]. The man, who had diabetes mellitus, hypercholesterolemia and arterial hypertension, was hospitalised for carotid endarterectomy. During the endarterectomy, he received heparin [unfractionated heparin] 5000U bolus. Additionally, he had been receiving treatment with various concomitant medications. Prior to the surgery, the platelet count was 143 × 103/µL that decreased to 115 × 103/µL on post operative day 3. Thereafter, his platelet count gradually increased and reached to 138 × 103/µL on post operative day 7. Thereafter, decreased in the platelet count was noted on post operative day 11. At that time, he was not receiving heparin; hence, heparin-induced thrombocytopenia was not considered. However, the platelet count again decreased to 91 × 103/µL and he scored 4 on the pretest clinical score for diagnosis of heparin-induced thrombocytopenia. On post-operative day 18, his platelet count decreased to 61 × 103/µL and his the pretest clinical score (4 T’s) was 5. His lab test sowed presence of heparin-induced thrombocytopenia antibodies. He was diagnosed with heparin-induced thrombocytopenia on post-operative day 19. Subsequently, he underwent IgG-specific ELISA that showed positive result for heparin-induced thrombocytopenia and his subsequent platelet aggregation test confirmed autoimmune heparin-induced thrombocytopenia [duration of treatment to reaction onset not stated]. Renal insufficiency was also noted. The man started receiving fondaparinux-sodium [fondaparinux] 5 mg/day for heparin-induced thrombocytopenia and aspirin was suspended. No sing of venous/arterial thrombosis was observed and he was discharged on post-operative day 23. During follow-up visits, it was noted that he had further decrease in the platelet count and he developed calf pain and swelling on post-operative day 27. An ultrasound of the leg showed a thrombosis in the internal gastrocnemius vein and the soleal vein, that was isolated distal deep vein thrombosis. Hence, failure of fondaparinux-sodium therapy was considered and the treatment was switched to rivaroxaban. Gradually, his platelet count returned to baseline. Twenty day after discontinuation of fondaparinux-sodium, he was asymptomatic and repeated ultrasound revealed recanalisation of the calf deep vein thrombosis. Later, the dose of rivaroxaban was decreased and his immunoassay still showed positive result for PF4-heparin complexes. Three months later, rivaroxaban was discontinued, an ultrasound of leg showed no thrombosis and the gel immunoassay showed a negative result for heparin complexes. At the one year follow-up visit, no recurrence of the thrombosis was noted. Sartori M, et al. Failure of Fondaparinux in Autoimmune Heparin-Induced Thrombocytopenia. TH Open 4: E305-E308, No. 4, 2020. Available from: URL: http:// doi.org/10.1055/s-0040-1713175
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