The Appropriateness of Testing Platelet Factor 4/Heparin Antibody in Patients Suspected of Heparin-induced Thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an adverse reaction to the administration of heparin due to the activation of the platelets by the immunoglobulin G (IgG) antibody-platelet factor 4 (PF4)/heparin immune complex. Since the clinical outcome is uncertain (as it could be associated with significant morbidity and sometimes death), an early diagnosis and appropriate treatment are necessary. The 4Ts pretest clinical scoring system and testing for all anti-PF4/heparin antibodies can markedly improve the diagnosis and prompt adequate treatment. Our study was undertaken to retrospectively evaluate the appropriateness of ordering the PF4 enzyme-linked immunosorbent assay (ELISA) test by using the 4Ts scoring system in a tertiary institution. We examined a database of 118 patients who had the PF4 ELISA test and calculated their 4Ts scores retrospectively. A total of 107 patients were evaluated; 95 patients (88.79%) had a negative PF4 ELISA assay and 12 patients tested positive (11.21%). Only one patient tested weakly positive in the low probability group (negative predictive value 98%). In the intermediate group, six patients were strongly positive (optical density (OD) > 1.0). In this latter group, further confirmatory testing using serotonin release assays (SRAs) could have been done. We also evaluated the setting where the tests were performed and found that the majority of patients (63.55%) were tested in the intensive care unit (ICU) where thrombocytopenia is multifactorial. We concluded that the large majority of patients were not appropriately evaluated prior to testing, which incurred unnecessary expense and patient distress. For the proper identification of patients suspected of HIT who should undergo PF4/heparin antibody testing, further education of the ordering physicians is recommended.

Minimal change disease: A case report of an unusual relationship.

Kidney injury associated with lymphoproliferative disorders is rare, and the exact pathogenetic mechanisms behind it are still poorly understood. Glomerular involvement presenting as a nephrotic syndrome has been reported, usually secondary to membranoproliferative glomerulonephritis. We report a case of a 63-year-old male who presented with bilateral leg swelling due to nephrotic syndrome and acute kidney injury. A kidney biopsy showed minimal change disease with light chain deposition; however, no circulating light chains were present. This prompted a bone marrow biopsy, which showed chronic lymphocytic leukemia (CLL) with deposition of the same kappa monoclonal light chains. Three cycles of rituximab and methylprednisolone resulted in remission of both CLL and nephrotic syndrome, without recurrence during a three-year follow-up.

Massive Retroperitoneal Hemorrhage as an Initial Presentation of a Rare and Aggressive Form of Multiple Myeloma.

Multiple myeloma, a plasma cell neoplasm, presents most commonly with anemia, hypercalcemia, renal failure, and bone pain. Only few cases of clinical aggressive presentation associated with bleeding were reported in the medical literature. The reported cases included gastrointestinal bleeding and cardiac tamponade. Spontaneous retroperitoneal haemorrhage as initial presentation has not been so far reported. We hereby report a case of a 64-year-old female who was found to have catastrophic hemorrhage in the retroperitoneal region that extended into intrathecal space causing cord compression. The case posed a significant diagnostic and management dilemma. This case emphasizes the need to think broadly and include multiple myeloma in the diagnosis of unexplained massive retroperitoneal bleeding.