Case 145 – continued

The critical care team inform you that while he was on LMWH prophylaxis whilst an inpatient for his acute appendicitis, he has not had any further heparin exposure in the last three weeks.

Further investigations are arranged with results as follows:

Blood film – a few red cell fragments (<1 per high power field) and polychromasia. Mild thrombocytopenia. No other diagnostic features.

ANCA – negative
ANA – weak positive with negative extractable nuclear antibodies
Anti-cardiolipin IgG 62 U/mL (0-10)
Anti-beta2-glycoprotein IgG 41 U/mL (0-7)

CT TAP has been requested to exclude underlying malignancy.

Given the degree of renal impairment and the require for invasive procedures (line insertions, etc.), you advise the critical care team to commence an unfractionated heparin infusion with anti-Xa monitoring due to the prolonged baseline aPTT.

What is the most likely diagnosis here?

What would you advise regarding the patient’s antiplatelet therapy – should this continue if starting UFH?

Given the most likely diagnosis, what treatment options are available and which ones would you initially recommend?

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