Thein Kyaw Z, Elsaim Sarah A, Ma Maggie Q, Rojas Hernandez Cristhiam M, Elsayem Ahmed
Target Therapy, University of Texas MD (Monroe Dunaway) Anderson Cancer Center, Houston, USA.
Medical School, University of Texas MD (Monroe Dunaway) Anderson Cancer Center, Houston, USA.
Cureus. 2022 Nov 22;14(11):e31798. doi: 10.7759/cureus.31798. eCollection 2022 Nov.
Heparin-induced thrombocytopenia (HIT) is an adverse reaction to heparin products, but not warfarin. HIT usually occurs 5‒10 days after exposure to heparin. Here, we report a case of HIT with multiple thrombotic events and severe thrombocytopenia resulting from intermittent intravenous heparin flushes for maintenance of a newly placed subclavian central venous catheter (CVC) for stem cell transplant. The patient is a woman in her forties with multiple myeloma who presented to the emergency department (ED) with dyspnea, pleuritic-type chest pain, hemoptysis, and worsening left-leg swelling. Heparin had been used to flush the CVC. Her platelet count began dropping approximately one week after insertion. The patient was receiving other medications known to cause thrombocytopenia. She had undergone multiple platelet transfusions. In the ED, her lab results showed thrombocytopenia), anemia; renal insufficiency; and elevated troponin, prothrombin time, and D-dimer levels. Because of the hemoptysis and thrombocytopenia, she initially received platelet transfusion and oxygen. She was found to have deep vein thrombosis of the lower extremity and started a referral to interventional radiology for inferior vena cava (IVC) filter placement. However, further review and consultation of the Benign Hematology service, discussion about the timing of decreased platelet count shortly after CVC placement and heparin administration, and the presence of thrombosis, suggested a high pre-test probability of HIT. Anticoagulation with argatroban was initiated, and IVC filter insertion was canceled. Further workup confirmed HIT diagnosis and saddle pulmonary embolism. During the patient's hospitalization, her platelets continued to improve and reached baseline upon discharge. She was transitioned to fondaparinux at the time of discharge. A few weeks later, she had successful stem cell transplantation. Emergency physicians treating patients with thrombocytopenia receiving heparin, even in small amounts, should consider the possibility of HIT and be familiar with its management.
肝素诱导的血小板减少症（HIT）是对肝素类产品而非华法林的一种不良反应。HIT通常在接触肝素后5至10天发生。在此，我们报告一例因间歇性静脉注射肝素冲管以维持新置入的锁骨下中心静脉导管（CVC）用于干细胞移植而导致的伴有多次血栓事件和严重血小板减少症的HIT病例。患者为一名四十多岁的患有多发性骨髓瘤的女性，因呼吸困难、胸膜炎样胸痛、咯血和左腿肿胀加重就诊于急诊科（ED）。肝素曾用于冲管CVC。她的血小板计数在置管后约一周开始下降。患者正在接受其他已知可导致血小板减少症的药物治疗。她接受了多次血小板输注。在急诊科，她的实验室检查结果显示血小板减少、贫血、肾功能不全以及肌钙蛋白、凝血酶原时间和D - 二聚体水平升高。由于咯血和血小板减少，她最初接受了血小板输注和吸氧治疗。她被发现患有下肢深静脉血栓形成，并开始转诊至介入放射科进行下腔静脉（IVC）滤器置入。然而，进一步的检查以及血液科良性疾病服务的会诊、关于CVC置管和肝素给药后不久血小板计数下降的时间以及血栓形成的讨论，提示HIT的预测试概率很高。启动了阿加曲班抗凝治疗，并取消了IVC滤器置入。进一步检查确诊为HIT诊断和鞍状肺栓塞。在患者住院期间，她的血小板持续改善，出院时达到基线水平。出院时她改用磺达肝癸钠。几周后，她成功进行了干细胞移植。治疗接受肝素治疗（即使是少量）且伴有血小板减少症患者的急诊医生应考虑HIT的可能性，并熟悉其管理方法。
