Case 145 – the beginning

You are on-call for haematology and receive a call from the critical care team regarding a 36-year-old male with a complex medical history. With the exception of an episode of uncomplicated acute appendicitis 3 weeks ago which required a laparoscopic appendicectomy, he was otherwise previously fit and well. He was admitted to hospital 7 days ago with right hemiparesis and dysphasia – imaging demonstrated thrombus within the left middle cerebral artery. He received systemic thrombolysis with altepase with a good neurological response and was then commenced on aspirin 300 mg daily.

Three days into his admission while he was being worked up for the cause of his stroke, he developed central chest pain – troponin T was significantly elevated at 623 ng/L. Cardiology took him to the cath lab for a primary PCI; however, his coronary arteries appeared patent on angiography. ECG showed sinus rhythm and his echocardiogram was unremarkable with good LV function.

Over the next three days, he developed shallow skin ulcers affecting his shins and an acute kidney injury. He then deteriorated suddenly with features of acute respiratory distress syndrome and was transferred to intensive care where he was immediately intubated and ventilated. The admitting critical care doctor notices that his right leg is swollen and doppler ultrasound confirms a proximal DVT. CTPA did not demonstrate any associated large PE.

Prior to commencing anticoagulation, the critical care team note that his coagulation profile (below) is abnormal and call for advice both on the safety of anticoagulation and for advice on any further investigations for this very thrombotic patient.

What advice would you give them on anticoagulation? What would be your choice of anticoagulant in this patient and why?

What further investigations would you recommend?

Full blood count
Hb 102            (130-180)
MCV 99           (80-100)
Platelets 123   (150-450)
WCC 14.2        (4.0-11.0)
Lymph 2.1       (0.5-3.5)
Neut 10.8        (2.0-8.0)
Eosin 0.3         (0.1-0.5)
Baso 0.1          (0.0-0.1)
Mono 1.0        (0.2-1.2)
Retic 120         (20-80)

Coagulation
PT 15               (11-15)
APTT 61           (25-35)
Fibrinogen 6.7 (1.5-5.0)


Biochemistry
Na 142            (133-146)
K 5.9                (3.5-5.3)
Creat 310        (45-85)
Bili 35              (0-21)
ALT 49             (0-40)
ALP 102           (30-130)
CRP 113           (0-5)

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