Eltrombopag/heparin/immune globulin
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Paradoxical reaction in the form of cerebral venous sinus thrombosis and progression of the cerebral venous sinus thrombosis: case report A 39-year-old woman developed paradoxical reaction in the form of cerebral venous sinus thrombosis during treatment with eltrombopag for chronic immune thrombocytopenic purpura (ITP). Additionally, she experienced progression of the cerebral venous sinus thrombosis following treatment with immune globulin and heparin as anticoagulant therapy [not all dosages, routes and indications stated; time to reaction onsets not stated]. The woman presented with severe headache, nausea and vomiting which she had been experiencing since four days. Her medical history was significant for type 2 diabetes mellitus and chronic ITP. She had been receiving eltrombopag for chronic ITP and was not compliant. On examination, she was initially alert and oriented. On neurologic examination, she showed neck stiffness. Laboratory tests revealed elevated leukocyte count and a low platelet count. CT scan of the head and venogram were performed and revealed cerebral venous sinus thrombosis involving bilateral transverse sinuses, left sigmoid sinus, torcular Herophili, and posterior aspect of the superior sagittal sinus. Within a couple of hours, her GCS dropped. A repeat CT scan was done and showed extension of thrombosis involving the entire superior sagittal sinus, cortical veins, left transverse and sigmoid sinuses bilaterally and the left internal jugular vein. She was admitted to the ICU. The cerebral venous sinus thrombosis was considered as paradoxical reaction secondary to treatment with eltrombopag. The woman started receiving platelet transfusion, dexamethasone, and IV immune globulin [immunoglobulin]. She also received heparin infusion. On the following day, her platelet count improved. Anticoagulation with heparin infusion was continued. However, on day 3, she further deteriorated while in ICU. She became more drowsy. Repeated imaging showed extensive progression of the cerebral venous sinus thrombosis along with bilateral frontal venous infarcts with frontal subarachnoid haemorrhage. The progression of the cerebral venous sinus thrombosis was suspected to be secondary to immune globulin and heparin. Her imaging study indicated ongoing thrombotic event. Heparin infusion was continued with target activated partial thromboplastin time of double the normal target. She received immune globulin for two days and dexamethasone for four days. Her hospital course was complicated by significant bleeding, which required blood transfusions. She developed widespread ecchymosis. Heparin was discontinued and resumed on the following day due to newly discovered partial right internal iliac artery thrombosis and left common iliac vein thrombosis. She initiated treatment with hydroxychloroquine. After 2 weeks, she became more alert. Repeated imaging showed near complete resolution of previous thrombosis with new evolution of the right anterior frontal small hemorrhagic infarction. After resolving thrombosis w
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