This article describes the case of a 63-year-old female patient who developed heparin-induced thrombocytopenia, associated with arterial and venous thrombosis.
The patient presented to the emergency department 15 days after a knee replacement surgery with symptoms of hyperpyrexia, headache, right hemiplegia in addition to altered consciousness and cloned tremors of the right limb and abdomen that lasted for about 2 minutes. Similarly, the computerised tomography of the brain was unremarkable. However, magnetic resonance imaging was remarkable of acute ischemia of the of the postcentral and precentral rounds of the left brain hemisphere. In addition, a subacute ischemic lesion was also evident in the right parietal region. All laboratory findings were within normal range, except for modest anaemia, thrombocytopenia and an elevated D-Dimer.
Further investigations were taking place in the neurology department.
The patient underwent a knee replacement surgery for osteoarthritis on April 2019 and was given subcutaneous enoxaparin 40 mg for thromboembolic prophylaxis, once a day.
History and examination
The patient’s medical history revealed that she was negative for risk factors of arterial thrombosis. There was no history of hypertension, diabetes or hypercholesterolemia. In addition, she had never smoked or taken estroprogestins. Moreover, was not overweight either. Clinical examination showed severe aching in the right hypochondrium with normal liver and spleen size. There was no sign of mucous-cutaneous bleeding.
Electrocardiogram and the echocardiography revealed a sinus rhythm with a nondilated left atrium and a normal ejection fraction (65%) of the left ventriculum. Therefore, excluded atrial fibrillation and any other causes of cardioembolism. The ultrasound of the supra-aortic trunks did not show any abnormalities. However, the CT scan of the thorax showed a pulmonary embolism with a minus imaging on the main branch of the left pulmonary artery. Although, the patient was asymptomatic.
There was pain in the right hypochodrium on liver palpation. CT scan of the abdomen showed a minus imaging on the segmentary branches on the right suprahepatic artery. However, the portal vein was free of any atherosclerotic lesions. Venous ultrasound of the lower limb showed a non-recent left superficial femoral and popliteal vein thrombosis. Moreover, repeat laboratory tests using a test tube containing citrate instead of ethylenediaminetetraacetic acid confirmed low platelet count.
The findings were consistent with the diagnosis of heparin-induced thrombocytopenia.
Treatment
Enoxaparin was discontinued and the patient was given a subtherapeutic dose of subcutaneous fondaparinux 5 mg, once a day. The patient now weighed 70 kg. Repeat brain MRI showed a hemorrhagic evolution of the acute ischemic cerebral lesion.
Three days after admission, there was a new episode of hyperpyrexia. Additionally, a chemical-physical urine test was showing a collection of erythrocytes, leukocytes, bacteria, and albuminuria. Moreover, was administered IV ciprofloxacin 400 mg bid. Urine culture was remarkable of multiresistant Escherichia coli infection. Laboratory results suggested urospesis. After discontinuing ciprofloxacin, the patient was started on meropenem therapy. Similarly, 20 ml/kg of fresh frozen plasma was given to the patient.
After treatment, the patient showed complete recovery in 5 days. A new CT scan at 6-month follow up showed bilateral ischemic outcomes and a complete recanalization of the pulmonary vascular bed and the right suprahepatic vein.
References
A “Catastrophic” Heparin-Induced Thrombocytopenia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7174963/
