Heparin
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Heparin-induced thrombocytopenia and thrombosis: case report A 44-year-old man developed heparin-induced thrombocytopenia and thrombosis (HITT) during anticoagulant therapy with heparin. The man had a history of thalassemia suffered with fever and cough for 3 days and, subsequently diagnosed with Coronavirus disease (COVID-19). On 26 March 2020, day 9 of diagnosis, he developed dyspnoea and he was transferred to the current hospital. Further investigations were found to be normal except elevated D-dimer. The chest X-ray demonstrated bilateral moderate to severe infiltration with ill-defined patchy opacities. Other than COVID-19, all the viral and bacterial tests were found to be negative. Thereafter, he was started on off-label treatment with oral hydroxychloroquine 200mg thrice daily and invasive mechanical ventilation. However, on day 11, he developed sudden onset of cardiac arrest, ventricular arrhythmia and received emergent cardiopulmonary resuscitation. Laboratory workup showed elevated creatine kinase, creatine kinase-myoglobin and D-dimer. An ECG demonstrated S-T segment elevation on the V1, V2, and V4 leads. Based on symptoms and findings, he was diagnosed with acute anteroseptal myocardial infarction. On day 12, due to the persistent cardiogenic shock, he was initiated on extracorporeal membrane oxygenation (ECMO) with continuous infusion of anticoagulant therapy of heparin 20 IU/kg (bolus dose) to keep activated partial thromboplastin time ratio between 1.5 and 2.0. He did not receive heparin therapy before the attack of the myocardial infarction. Within 12 hours of initiation of heparin therapy, he developed HITT, which was confirmed by 4T’s score over 6 and strong positive on immunoassay. As the dose of heparin accumulated and COVID-19 progressed, he developed episodes of ventricular arrhythmia, severe upper gastrointestinal tract bleeding, hypercoagulability and repeated myocardial infarctions with increased creatine kinase-myoglobin and creatine kinase levels. After 23rd hours of application of ECMO, he died because of cardiac failure. Huang C-T, et al. Heparin-induced thrombocytopenia and thrombosis in a patient with Covid-19. Thrombosis Research 196: 11-14, Dec 2020. Available from: URL: http:// 803500341 doi.org/10.1016/j.thromres.2020.07.056
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Reactions 12 Sep 2020 No. 1821
