Which Septic Shock Patients With Non-Overt DIC Progress to DIC After Admission? Point-of-Care Thromboelastography Testing.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a life-threatening complication of septic shock; however, risk factors for its development after admission are unknown. Thromboelastography (TEG) can reflect coagulation disturbances in early non-overt DIC that are not detected by standard coagulation tests. This study investigated the risk factors including TEG findings as early predictors for DIC development after admission in septic shock patients with non-overt DIC. METHODS: This retrospective observation study included 295 consecutive septic shock patients with non-overt DIC at admission between January 2016 and December 2019. DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5. The primary outcome was non-overt DIC at admission that met the ISTH DIC criteria within 3 days after admission. RESULTS: Of the 295 patients with non-overt DIC, 89 (30.2%) developed DIC after admission. The DIC group showed a higher ISTH score and 28-day mortality rate than the non-DIC group (2 vs. 3, P < 0.001; 13.6% vs. 27.0%, P = 0.008, respectively). The DIC rate increased with the ISTH score (7.7%, 13.3%, 15.8%, 36.5%, and 61.4% for scores of 0, 1, 2, 3, and 4, respectively). Among TEG values, the maximum amplitude (MA) was higher in the non-DIC group (P < 0.001). On multivariate analysis, an MA < 64 mm was independently associated with DIC development (odds ratio, 2.311; 95% confidence interval, 1.298-4.115). CONCLUSIONS: DIC more often developed among those with admission ISTH scores ≥ 3 and was associated with higher mortality rates. An MA < 64 mm was independently associated with DIC development in septic shock patients.

Disseminated carcinomatosis of the bone marrow from gastric cancer during pregnancy.

Gastric cancer during pregnancy is extremely rare and difficult to diagnose at early stages because of its nature. Furthermore, it is often difficult to determine the appropriate treatment strategy considering both the patient's condition and the effect of the treatment on the fetus. We present a case of a 34-year-old woman with gastric cancer who was 22 weeks pregnant and had multiple liver and bone metastases at the time of diagnosis. The disease progressed to disseminated carcinomatosis of the bone marrow, in which cancer invades and spreads diffusely to the bone marrow and then presents disseminated intravascular coagulation. Fortunately, the selected systematic chemotherapy dramatically reduced the severity of the patient's cancer and she could deliver her baby successfully. There are few reports of disseminated carcinomatosis of the bone marrow from gastric cancer during pregnancy. Even in such an oncological emergency, prompt chemotherapy saved the mother's life and enabled safe delivery of the fetus.

Whole genome analysis of a multidrug-resistant Streptococcus pneumoniae isolate from a patient with invasive pneumococcal infection developing disseminated intravascular coagulation.

Multidrug-resistant Streptococcus pneumoniae strains were isolated from blood and sputum of a patient with disseminated intravascular coagulation in Sapporo city, Japan. These antibiograms were only susceptible to vancomycin, linezolid, daptomycin, some carbapenems, and some fluoroquinolones. Identical antibiograms, serotypes (19F), and sequence types (ST10017) suggested a shared origin of these isolates. Only one ST10017 strain has been isolated in the same city in Japan previously (2014), and the 2014 isolate is still susceptible to macrolides. The whole genome of the blood-derived isolate was sequenced. The strain harbored resistance mutations in parC, gyrA, pbp1a, pbp2a, pbp2b, and pbp2x, and harbored the resistance genes, ermB and tetM. The nucleotide sequences of parC and pbp2x genes of strain MDRSPN001 were clearly different from those of other S. pneumoniae strains and were similar to those of oral streptococci strains. These findings suggest that strain MDRSPN001 has been rapidly and drastically evolving multidrug resistance by gene replacement and accumulation of genes originating from other strains, such as oral streptococci, Streptococcus mitis.

Bilateral orbital compartment syndrome in a patient with disseminated intravascular coagulation.

A 39-year-old male developed bilateral periorbital oedema and tense orbits in keeping with orbital compartment syndrome (OCS) shortly after presenting to the emergency department for uncontrollable epistaxis. Bilateral lateral canthotomy and inferior cantholysis was performed within 30 minutes of onset, with the left side further decompressed via superior cantholysis. Computed tomography demonstrated bilateral proptosis and optic nerve stretch, but no intraorbital haemorrhage or haematoma. Laboratory findings were consistent with disseminated intravascular coagulation (DIC) and sepsis of unknown origin. The right visual acuity recovered to 6/6 -2 from counting fingers, but the left eye failed to improve beyond light perception. This unique case of OCS is the first associated with DIC which had no evidence of intraorbital haemorrhage.

Dramatic response of acute disseminated intravascular coagulation to erlotinib in a patient with lung adenocarcinoma with activating EGFR mutation.

Disseminated intravascular coagulation (DIC) is a commonly encountered clinical situation characterized by thrombotic occlusion or bleeding in patients with lung cancer. DIC in patients with cancer is usually asymptomatic, taking a chronic form as a compensatory mechanism. Although acute DIC in patients with lung cancer is rarely reported, it can be fatal. We herein describe a patient with lung adenocarcinoma with an activating mutation of the epidermal growth factor receptor (EGFR) gene who developed acute DIC after minor surgical excision. The patient's condition dramatically improved immediately after administration of erlotinib. This report alerts physicians to the occurrence of acute DIC and serves as a reference in treating EGFR mutation-positive lung cancer in patients with DIC.

Use of uterine artery embolization to prevent peripartum hemorrhage of placental abruption with fetal demise & severe DIC.

Uterine artery embolization (UAE) is typically not indicated in the pre-operative management of pregnancies with a live fetus, because risk of fetal death from reduced uteroplacental blood flow. However, pre-operative UAE in pregnancies with a fetal demise poses no fetal risk, and may offer maternal benefits. Patients with placental abruption resulting in fetal demise are at high-risk for developing disseminated intravascular coagulation (DIC), which could have devastating complications such as peri-operative hemorrhage and death. This case report describes the first successful execution of a pre-operative UAE that effectively prevented antepartum and postpartum hemorrhage in a patient with DIC secondary to a placental abruption and recent fetal demise.

Koagulopatia ze zuzycia jako wiodacy objaw zatoru plynem owodniowym -opis przypadku.

Amniotic fluid embolism is a rare and diagnostically challenging obstetric disease of high mortality rate. We present a case of a 33-year old parturient after vaginal birth, who presented with severe hemorrhagic shock with low platelet count and coagulopathy resistant to treatment with plasma, platelets and coagulation factors and despite of surgical management of bleeding. Laboratory findings revealed consumptive coagulopathy. Other symptoms included dyspnea and atelectatic changes on chest x-ray, together with augmentation of the heart with no proof of ventricular insufficiency in echocardiographic examination. The suspected reason of these alterations was amniotic fluid embolism. The patient survived and came back to her usual activity after 22 days of treatment.

Disseminated Intravascular Coagulation in Secondary Glioblastoma due to Excessive Intraoperative Bleeding: Case Report and Review of the Literature.

BACKGROUND: Disseminated intravascular coagulation (DIC) describes a pathologic activation of coagulation mechanisms, leading to thrombi in various organs with contribution to multiple organ failure. In clinical practice, diagnosis of DIC can often be made by laboratory values, including prolonged coagulation times, thrombocytopenia, or high levels of fibrin degradation products. DIC is frequently observed after neurotrauma, but rarely occurs in patients with primary brain tumors. There are only few case reports of DIC in patients with primary brain tumors, all sharing the highly elevated mortality. We report the case of a young patient presenting with secondary glioblastoma, who developed multiorgan failure induced by DIC after extensive intraoperative bleeding. CASE DESCRIPTION: A 30-year-old patient was admitted in poor general condition with insomnia, severe headache, and vomiting. She had undergone surgery for secondary glioblastoma twice. Magnetic resonance imaging revealed a left temporoparietal mass lesion with indication for resection. Surgery then was complicated by diffuse intraoperative bleeding due to a high content of microvascular proliferation as shown in the histopathologic workup. Subsequently, an uncontrollable multiorgan failure developed, causing the patient's death 4 days after surgery. CONCLUSIONS: Although a rare complication, excessive intraoperative bleeding, especially in surgery for brain tumors located next to the ventricular system, DIC should be kept in mind as a possible diagnosis.

Intermittent administration of recombinant human soluble thrombomodulin successfully controlled chronic disseminated intravascular coagulation in a patient with dissecting aortic aneurysm on an outpatient basis.

Chronic disseminated intravascular coagulation (DIC) is a rare but life-threatening complication of dissecting aortic aneurysm. Although anticoagulant therapy may often proves effective for controlling DIC itself, patients would have to be hospitalized for a long period due to continuous infusion therapy. Subcutaneous injection of a highly concentrated preparation of heparin calcium may offer one alternative treatment for DIC; however, daily subcutaneous use of heparin for the treatment of DIC has impaired quality of life (QOL). The other alternative therapy is intravenous administration of recombinant human soluble thrombomodulin (rTM), which includes the active extracellular domain of thrombomodulin. Reportedly, rTM effectively resolves DIC by only 6 consecutive days of administration; however, how frequently rTM should be administered after the resolution of chronic DIC to have good control of it has been unclear. We report herein a case of chronic DIC complicated with dissecting aortic aneurysm, whose resolution of chronic DIC achieved by 6 consecutive days of rTM has been maintained by once a week administration of rTM on an outpatient basis.

Transarterial embolization for cervical hemangioma associated with Kasabach-merritt syndrome.

A 2-month-old girl presented with cervical hemangioma associated with Kasabach-Merritt syndrome. The patient had previously undergone systemic administration of corticosteroids (prednisolone 2 mg/kg/day) and radiotherapy (0.5 Gy × 5 times), which temporarily increased the platelet count, but the effects were short-lived and thrombocytopenia gradually worsened again despite increased dosage of prednisolone to 5 mg/kg/day. Computed tomography and magnetic resonance imaging revealed a hemangioma in the left retroauricular-cervical region with a well-enhanced, ill-defined margin and bony structure involvement. Diagnostic and therapeutic angiography were carried out through the femoral route under general anesthesia. Polyvinyl alcohol particles (250-350 µm) suspended in contrast medium were slowly injected and a fibered coil was finally placed in the proximal portion of the arterial feeder. Angiography after embolization revealed a marked reduction in the tumor stain. Platelet count rapidly increased and reached the normal range on postembolization day 7. Tumor tension decreased on the day after the procedure and tumor size gradually decreased. The patient was discharged with oral corticosteroid therapy at 6 months postembolization. Corticosteroid dose was gradually decreased and coagulation parameters were normal at 1 year postembolization.

Esophageal endoscopic ultrasound with fine-needle aspiration with an on-site cytopathologist: high accuracy for the diagnosis of mediastinal lymphadenopathy.

STUDY OBJECTIVES: To analyze the accuracy of esophageal endoscopic ultrasound (EUS) with real-time, guided fine-needle aspiration (EUS-FNA) with an on-site cytopathologist in patients with (presumed) lung cancer presenting with mediastinal lymphadenopathy (ML) or a suspect left adrenal gland (LAG). DESIGN: A single-center prospective study. PATIENTS: Sixty-seven outpatients with (presumed) lung cancer with ML or a suspect LAG on either CT and/or positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) scan. INTERVENTIONS: All patients underwent EUS-FNA under conscious sedation. A cytopathologist was present during all procedures. MEASUREMENTS: EUS with and without fine-needle aspiration (FNA) as compared to FDG-PET was evaluated for accuracy in diagnosing cancer, safety, and rate of avoidance for further surgery. RESULTS: Of 67 consecutive patients (56 men; median age, 64 years), malignant ML or LAG were found in 47 patients (70.1%). In 20 patients (29.9%) without EUS-FNA proof of malignancy, confirmation was obtained by surgical procedure in 13 patients (sarcoidosis [n = 5], infection [n = 1], lung cancer [n = 7]) or by clinical follow-up in 5 patients suggesting benign disease. Sixty-five patients were included in the calculation of test characteristics. With malignancy as an end point, the accuracy for EUS-FNA was 100%. This was better than EUS without FNA (accuracy, 75.4%; p < 0.001) or FDG-PET (accuracy, 75.0% [n = 28]; p = 0.0011). When using final histopathologic diagnosis as an end point, the accuracy of EUS-FNA was 92.3%, since EUS-FNA was unable to show noncaseating granulomas in those patients with sarcoidosis diagnosed after mediastinoscopy. Related to the presence of the in situ cytopathologist, there were no inconclusive samples. No adverse events were recorded, and 67.7% of surgical interventions were avoided following EUS-FNA. CONCLUSIONS: The accuracy in this series of EUS-FNA with cytopathologist-assisted rapid on-site evaluation is high. The technique is safe and greatly reduces the number of surgical interventions.

Effect of combined therapy of danaparoid sodium and tranexamic acid on chronic disseminated intravascular coagulation associated with abdominal aortic aneurysm.

Chronic disseminated intravascular coagulation (DIC) is a well-known complication of aortic aneurysm. A 63-year-old man with bleeding tendency and a large palpable abdominal aortic aneurysm (AAA) was diagnosed as having fibrinolysis dominant DIC by the excessive activation of both coagulation and fibrinolysis (plasmin -alpha2 plasmin inhibitor complex concentration is usually >4 microg/ml). Although several treatments were tried, DIC could not be controlled until the patient was given combined therapy of danaparoid (1,250 U/12 h, bolus IV) and tranexamic acid (0.5 g x 3/day, oral administration). This therapy may be beneficial when control for bleeding is required without restricting the ambulatory movement of patients by continuous drip.