2000 Associates' Presentations
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A Woman Presenting with Pulmonary Embolism, Renal Infarction and Myocardial Infarction
A.N. Kho, MD, University of Wisconsin Medical School, Madison, WI
Case: A 68 year old female presented to the emergency department with complaints of nausea and vomiting. Eleven days prior, the patient underwent coronary bypass surgery, and was discharged four days later with a platelet count of 195,000. Initial laboratory studies at admission revealed a WBC count of 15,400, platelet count of 61,000 and Troponin I of 4.4. Urinalysis was positive for occasional WBCs, 30-60 RBCs, occasional bacteria, but negative nitrite and leucocyte esterase. In the emergency department, an initial diagnosis of pyelonephritis was entertained, and a CT scan of the abdomen was ordered which revealed a possible infarct in the upper pole of the right kidney. Upon return from the scanner, the patient developed dyspnea and decreasing saturation on pulse oximetry and was sent for a ventilation-perfusion scan which returned with a high probability for pulmonary embolism. Based on the presentation of a renal infarction with pulmonary embolism in the contest of a precipituous drop in platelet count, the diagnosis of Heparin-Induced Thrombocytopenia was made. Serum was drawn for heparin-induced platelet antibody and the patient was started on lepirudin anticoagulation. The patient later ruled in by enzymes for a non-Q wave myocardial infarction. The ELISA for Heparin Induced Platelet Antibody against Factor IV returned strongly positive. The patient was transitioned to coumadin anticoagulation after three days of lepirudin and was discharged in good condition after an eight day hospitalization.
Discussion: Heparin-Induced Thrombocytopenia type II is a clinicopathologic syndrome characterized by arterial or venous thrombotic events precipitated by an immune complex formed between heparin and an antibody to platelet factor IV. In type II, platelet count reduction is often below 100,000, and serious thrombotic events can occur, including deep venous thrombosis, pulmonary embolism, myocardial infarction, and peripheral arterial clots. Treatment is the prompt discontinuation of heparin therapy, and initiation of antithrombotic therapy with specific thrombin inhibitors such as hirudin or argatroban.
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