Pulmonary Vascular Disease: Pulmonary Vascular Disease |

A Rare Case of Venous Thromboembolism Followed by Arterial Thrombosis FREE TO VIEW

Yi Chun Yeh, MD; Raymundo Quintana-Quezada, MD
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University of Texas Health Science Center at Houston, Houston, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A507. doi:10.1016/j.chest.2016.02.529
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SESSION TITLE: Pulmonary Vascular Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Disseminated intravascular coagulation (DIC) is commonly encountered within the medical intensive care unit (MICU). Usual manifestations include bleeding, ecchymosis, and blood oozing from puncture sites. We present an unusual case of venous thromboembolism (VTE) followed by developement of arterial thrombosis due to DIC.

CASE PRESENTATION: 36-year-old female is admitted due to acute-onset chest pain and found to have bilateral segmental pulmonary embolism. Her medical history was pertinent for juvenile idiopathic arthritis with symmetric joint deformations. Despite being on chronic steroids and rituximab for maintenance therapy, she had been having intermittent fevers for two weeks. Blood cultures obtained from the access port were positive for coagulase-negative Staphylococcus. Heparin and antibiotics were initiated. Anticoagulation was held due to INR of 5 on the second day of warfarin initiation. The next day, patient acutely developed excruciating right hand pain. Physical examination was pertinent for her right hand being erythematous with distinct border, swollen, and cool-to-touch (Figure 1). There were no palpable radial pulses and blood flow could not be detected by continuous wave Doppler. One hour later, similar presentation was seen in her left foot. Laboratory results were pertinent for INR >10, PT >100 seconds, PTT 97.9 seconds, fibrinogen <15 mg/dL, platelet 51 k/uL, pH of 7.13, and lactic acid of 6 mmol/L. Duplex Doppler of the extremities showed no detectable flow in the left dorsalis pedis and posterior tibial artery (PTA) (Figure 2). Reversal of flow was seen within the right subclavian and axillary arteries, with inverted diastolic flow in the remainder of the right upper extremity vessels. She was transferred to the MICU for severe DIC and metabolic acidosis. Patient was transfused with cryoprecipitate, fresh frozen plasma, platelets, and vitamin K. Low-dose continuous argatroban was initiated due to concerns for heparin-induced thrombocytopenia (HIT) and antibiotics were broadened. Dilute Russell's viper venom time was grossly abnormal but beta-2-gycoprotein was negative; ADAMTS13 activity was also normal. Peripheral smears showed 6-8 schistocytes/high power field. HIT panel was negative. Return of pulses were detected on day 4 of MICU stay.

DISCUSSION: The patient presented to us with sepsis and acute bilateral pulmonary embolism. We suspect VTE was the initial manifestation of compensated DIC, masked by normal coagulation parameters on presentation. ​This case demonstrates an unusual presentation of acute-on-chronic DIC with sequential arterial thrombosis of multiple limbs.

CONCLUSIONS: Physician should be wary of unexpected rise in coagulation parameters as this could be the forewarning sign of DIC and impending catastrophe.

Reference #1: Levi M et al. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 145.1 (2009): 24-33

DISCLOSURE: The following authors have nothing to disclose: Yi Chun Yeh, Raymundo Quintana-Quezada

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