Skin necrosis as the first symptom of heparin induced thrombocytopenia type 2 without thrombocytopenia- a case report

Kód výsledku v IS VaVaI

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Výsledek na webu

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DOI - Digital Object Identifier

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Jazyk výsledku

angličtina

Název v původním jazyce

Skin necrosis as the first symptom of heparin induced thrombocytopenia type 2 without thrombocytopenia- a case report

Popis výsledku v původním jazyce

Heparin induced thrombocytopenia- type 2 (HIT 2) is a lifethreatening immune mediated disorder, with IgG antibodies directed at the complex of heparin- platelet factor 4. It leads to neutralization of heparin anticoagulant effect, increase of thrombin level, hypercoagulation and thrombocytopenia. We found only two published case reports of skin necrosis as a symptom of HIT 2 without thrombocytopenia. Case report: We present a 45-year- old man with subclavian vein thrombosis followed by right side pulmonary embolism in July 2016. He had been treated by heparin and subsequently by warfarin. After his discharge home the warfarin therapy had continued. After two months, in October 2016, he was admitted to our ICU with acute respiratory failure and severe septic shock due to severe anaerobic pneumonia with a desintegration of middle and lower right lung lobe. He was intubated, mechanically ventilated, an empiric antimicrobial therapy was administered. INR was 2.6 and thrombocytes count 617 *109 on the day of admission. Warfarin was discontinued. The administration of enoxaparin was started on the day 5 in therapeutic dose of 8000 IU/12 hours according to anti Xa activity. On the day 11 a strange skin necrosis appeared in the abdomen where enoxaparin injections were administered. According to the "HIT score"a high suspicion of HIT 2 was pronounced although the platelet number was 290*109 (but it decreased by more than 50%). Haematological tests which confirmed HIT were done. The administration of enoxaparin was interrupted and the anticoagulation therapy was changed to fondaparin for 24 hours. Subsequently argatroban as a direct thrombin inhibitor was administered. Argatroban efficacy was monitored by APTT ratio. Therapy was converted to warfarin after the patient was stabilised and the skin necrosis have improved. The diagnosis of HIT cannot be excluded in patients with normal platelet count. This is especially important in ICU patients, who often have a higher platelet count. It is necessary to monitor blood count so that a significant decrease of platelets is noticed. Skin necrosis is a Methods: All the patients (n=25) received 3 500 UI of bemiparin per day, as non alternant-TED stockings. Results: The Wells and Geneva scores, at the admission as outcome dismiss thromboembolism, there were no deaths, nor adverse events associated to the administration of bemiparin. Conclusion: The pharmacological profile of bemiparin, suggests it as the first line drug in thromboprofilaxis in obstetric critical care. S272 Apresentação e-pôster Rev Bras Ter Intensiva. 2017;Supl. 1:S19-S322 very rare clinical symptom of HIT 2, but it can lead us to the diagnosis. Not only intensivists but all physicians should be looking for skin changes in patients treated by heparin. If any suspicion occurs, the patient should be given an alternative anticoagulation therapy until HIT can be excluded

Název v anglickém jazyce

Skin necrosis as the first symptom of heparin induced thrombocytopenia type 2 without thrombocytopenia- a case report

Popis výsledku anglicky

Heparin induced thrombocytopenia- type 2 (HIT 2) is a lifethreatening immune mediated disorder, with IgG antibodies directed at the complex of heparin- platelet factor 4. It leads to neutralization of heparin anticoagulant effect, increase of thrombin level, hypercoagulation and thrombocytopenia. We found only two published case reports of skin necrosis as a symptom of HIT 2 without thrombocytopenia. Case report: We present a 45-year- old man with subclavian vein thrombosis followed by right side pulmonary embolism in July 2016. He had been treated by heparin and subsequently by warfarin. After his discharge home the warfarin therapy had continued. After two months, in October 2016, he was admitted to our ICU with acute respiratory failure and severe septic shock due to severe anaerobic pneumonia with a desintegration of middle and lower right lung lobe. He was intubated, mechanically ventilated, an empiric antimicrobial therapy was administered. INR was 2.6 and thrombocytes count 617 *109 on the day of admission. Warfarin was discontinued. The administration of enoxaparin was started on the day 5 in therapeutic dose of 8000 IU/12 hours according to anti Xa activity. On the day 11 a strange skin necrosis appeared in the abdomen where enoxaparin injections were administered. According to the "HIT score"a high suspicion of HIT 2 was pronounced although the platelet number was 290*109 (but it decreased by more than 50%). Haematological tests which confirmed HIT were done. The administration of enoxaparin was interrupted and the anticoagulation therapy was changed to fondaparin for 24 hours. Subsequently argatroban as a direct thrombin inhibitor was administered. Argatroban efficacy was monitored by APTT ratio. Therapy was converted to warfarin after the patient was stabilised and the skin necrosis have improved. The diagnosis of HIT cannot be excluded in patients with normal platelet count. This is especially important in ICU patients, who often have a higher platelet count. It is necessary to monitor blood count so that a significant decrease of platelets is noticed. Skin necrosis is a Methods: All the patients (n=25) received 3 500 UI of bemiparin per day, as non alternant-TED stockings. Results: The Wells and Geneva scores, at the admission as outcome dismiss thromboembolism, there were no deaths, nor adverse events associated to the administration of bemiparin. Conclusion: The pharmacological profile of bemiparin, suggests it as the first line drug in thromboprofilaxis in obstetric critical care. S272 Apresentação e-pôster Rev Bras Ter Intensiva. 2017;Supl. 1:S19-S322 very rare clinical symptom of HIT 2, but it can lead us to the diagnosis. Not only intensivists but all physicians should be looking for skin changes in patients treated by heparin. If any suspicion occurs, the patient should be given an alternative anticoagulation therapy until HIT can be excluded

Druh

O - Ostatní výsledky

CEP obor

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OECD FORD obor

30223 - Anaesthesiology

Projekt

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Návaznosti

I - Institucionalni podpora na dlouhodoby koncepcni rozvoj vyzkumne organizace

Rok uplatnění

2017

Kód důvěrnosti údajů

S - Úplné a pravdivé údaje o projektu nepodléhají ochraně podle zvláštních právních předpisů