Concomitant use of argatroban and warfarin during hemodialysis in heparin-induced thrombocytopenia.

OBJECTIVE AND IMPORTANCE: The use of argatroban during hemodialysis in a patient receiving warfarin is not established. We present a case of heparin-induced thrombocytopenia in a patient on hemodialytic therapy who successfully received argatroban concomitantly to warfarin during renal replacement therapy. CLINICAL PRESENTATION: A 46-year-old male patient with autosomal dominant polycystic kidney disease presented with heparin-induced thrombocytopenia (HIT) arised during dialytic procedures. Intervention After the acute episode requiring argatroban and warfarin therapy, the patient continued to receive argatroban during the hemodialytic session concomitantly to warfarin. CONCLUSION: The administration of argatroban in the dialytic circuit of a patient on oral anticoagulant therapy can be considered an effective and safe approach.

Serum Thrombopoietin and cMpl Expression in Thrombocytopenia of Different Etiologies.

The relationship between thrombopoietin (TPO) and its receptor cMpl in thrombocytopenic conditions has not been entirely clarified. To elucidate this interplay may expand the spectrum of indications of TPO mimetics. In this study we have explored the relationship between TPO and cMpl in platelets and megakaryocytes of 43 patients with thrombocytopenia due to idiopathic thrombocytopenic purpura (ITP), bone marrow hypoplasia, myelodysplastic syndromes (MDS), and familial thrombocytopenia. Data were compared to cMpl and TPO in patients with a normal platelet count and in patients with thrombocytosis due to essential thrombocythemia (ET). All but familial patients showed higher TPO compared to controls. All thrombocytopenic states were invariably associated with increased expression of platelet cMPL compared to healthy controls. ET patients showed normal TPO and a trend toward a reduced cMpl expression. Immunofluorescence of bone marrow sections from patients with ITP and MDS failed to show a peculiar pattern compared to controls. Multiple mechanisms regulate TPO and cMpl in thrombocytopenic conditions.

Bleeding manifestations apparently unrelated to coagulation or other organic disorders: A tentative classification and diagnostic clues.

OBJECTIVE: To study the features of bleeding conditions apparently not associated with vascular, platelet, or clotting dysfunctions. METHOD: Conditions that may meet these criteria are: Münchausen syndrome factitious or fictitious, suicidal or homicidal bleeding, bleeding due to self-punishment, stigmatization, the battered child syndrome, and psychogenic bleeding. RESULTS: The importance of these variegate conditions is not trivial in clinical practice. Differential diagnosis may be difficult and involve other specialists besides hematologists. Occasionally, invasive procedures are involved. DISCUSSION: The occurrence of bleeding in patients, without a clotting defect or a systemic disorder and a negative family history for bleeding represents a diagnostic challenge. A careful examination of the physical and psychological status of the patient and an appropriate evaluation of the environment in which bleeding occurs, is always needed.

Venous thrombosis in rare or unusual sites: a diagnostic challenge.

Venous thrombosis usually involves the veins of the limbs, most frequently the leg veins. All other venous districts may sometimes be affected by the thrombotic process. Sometimes, the thrombotic occlusion of the veins of a given region show typical signs and symptoms. In other cases, the picture may not be clear and a high degree of clinical suspicion is needed for a correct approach to patient diagnosis and management. Thrombosis of retinal and jugular veins, right heart thrombosis including thrombosis of coronary sinus and thrombosis of the azygos system may be included in this group. In addition, thromboses of umbilical, renal, ovarian, spermatic, and iliac veins also require attention. Finally, the dorsal veins of the penis may also be affected by thrombotic events. The main clinical features of these thromboses are reviewed herein with suggestions for a correct diagnostic approach. The importance of sonography and of other imaging techniques is emphasized. A prompt diagnosis is of paramount importance as most of these thromboses in rare or unusual sites may still cause severe systemic complications (pulmonary embolism, sepsis, and heart failure).

Arterial and venous thromboses in patients with idiopathic (immunological) thrombocytopenia: a possible contributing role of cortisone-induced hypercoagulable state.

Immunological thrombocytopenias, as other forms of thrombocytopenia, are associated with bleeding. Occasionally, these patients manifest thrombotic events. A total of at least 29 patients were reported to have had either arterial (20 cases) or venous (9 cases) thrombosis while platelet count was less than 50 × 10(3)/µL. The most frequent clinical manifestation was a myocardial infarction. Thrombosis occurred in the large majority of patients during prednisone therapy. Patients receiving cortisone or patients with Cushing syndrome show a hypercoagulable state characterized by elevated factor VIII levels, decreased fibrinolysis, and abnormal von Willebrand factor multimers composition. The same is probably true for prednisone-treated patients with thrombocytopenia. However, the 2 conditions are not identical since prednisone is a mainly glycoactive compound, whereas cortisol produced in excess in Cushing syndrome is mainly mineraloactive. The presence of large, young, hyperactive platelets may also play a role. Prednisone-treated patients with thrombocytopenia have to be considered as potentially thrombophilic.

Congenital Thrombophilia and Intracardiac Thrombosis: Probably an Underdiagnosed Event.

BACKGROUND: To investigate the number of patients with congenital thrombophilia who presented an intracardiac thrombosis. METHODS: Personal files were reevaluated together with a time-unlimited search of the literature. RESULTS: Twenty-five patients with intracardiac thrombosis and congenital thrombophilia have been gathered from the literature including the two personal cases. The distribution observed in thrombophilia patients is similar for left side or right side heart (9 vs 11 cases). The left ventricle and the right ventricle were involved in six or five instances, respectively. In one case, both ventricles were involved. On the contrary, the left atrium was involved in three cases whereas the right atrium was affected in six cases. In the remaining cases, more than one heart chamber was involved. CONCLUSIONS: In "normal" subjects, left side thromboses are predominant once catheter-associated thrombi are excluded. The reason of this discrepancy lies in the greater prothrombotic effect exercised by congenital thrombophilia on venous thrombosis compared to arterial thrombosis. The relative high prevalence of cardiac thrombosis seen in patients with antithrombin and protein C deficiencies indicated that a cardiac evaluation should be carried out in all patients with these two defects.

Considerations on a tentative classification of FVII deficiency suited for practical clinical purposes.

Adequate classifications of disorders are of paramount importance in the management of congenital bleeding disorders. Classification of congenital FVII deficiency should be simple, based on few tests using thromboplastins of different origin. The first thromboplastin to be used is a rabbit brain preparation since it has been proven that this is the one that, overall, yields the lowest activity level. This is particularly so since molecular biology techniques have supplied important information with regard to the structure-function relation but have failed to supply a satisfactory classification of the defect. Mutations in the same domain have yielded different forms of FVII deficiency. Furthermore, molecular biology techniques are time consuming and are not feasible in every laboratory. A classification of FVII deficiency based on clinical, clotting, and immunological assays is proposed. This classification is suited for practical clinical purposes and may represent a useful preparatory basis for molecular biology studies.

Epidemiology of primary and secondary thrombocytopenia: first analysis of an administrative database in a major Italian institution.

Administrative databases can be a reliable source for estimating the epidemiology of blood disorders. No data are available estimating the epidemiology of thrombocytopenia from administrative data in Italian institutions. We analyzed the administrative database of the Padua University Hospital with the aim to study the epidemiology of thrombocytopenia in patients discharged with an International Classification of Disease, 9th Revision, Clinical Modification (ICD9-CM) code of thrombocytopenia. The database from year 2004 to 2008 was evaluated and all cases of thrombocytopenia (Code 287.1, 3, 4, 5) were identified and analyzed with regard to age, sex, associated diseases, therapeutics procedures and bleeding complications. The accuracy of electronic records was validated in all available medical records of patients discharged in 2009, by applying the ICD9-CM update 2007 version (Code 287.1, 4, 5; 287.30, 31, 32, 33, 39). We found 368 patients discharged from 2004 to 2008 with an ICD9-CM code of thrombocytopenia, correspondent to 0.1% of discharge rate and to a rate of 73.6 patients/year. The incidence of thrombocytopenia for this period was 14.8 cases per 100,000 per year. When considering patients with an ICD9-CM diagnosis of immune thrombocytopenia (ITP: Code 287.3), the incidence was of 6.8 cases per 100,000 per year. The clinical records of 40 patients with a discharge diagnosis of thrombocytopenia during year 2009 were reviewed for clinical consistency with ICD9-CM codes. A concordant diagnosis between clinical records and discharge code was found in 82.5% of cases. Following validation of ICD9-CM code, the incidence of ITP (Code 287.31) was 2.6 cases per 100,000 per year. When evaluated for sensitivity and specificity, we found the ICD-9-CM to be useful in studying thrombocytopenia using administrative data.