Cases from the Lab: Heparin Induced Thrombocytopenia Are we there yet

1. Cases from the Lab:Heparin Induced ThrombocytopeniaAre we there yet?

2. CR, 53 year old gentleman Severe pain of B/L toes -3/7. P/H � APA syndrome DVT /PE -1994 on warfarin - Small vessel vasculitis (1989 treated with steroids) - Type II DM - IHD - Renal Calculi - Diverticular Disease � recent colonoscopy. Medications � Warfarin, Aspirin( ceased) Recently Bridged with LMWH for colonoscopy

3. Examination � � Not unwell looking� Peripheral pulses intact Tender toes and ears, blue toe. Tender abdomen - collapsed with pain Investigations at admission - Hb- 140 TC-9.3 Plt-101 Na-135 K-3.6 Creat-85 APTT-44 INR-1.3 (ACA -174 ANA -1280) XRC � No gas under diaphragm CT abdomen � adrenal mass ?tumour ?haematoma.- MRI recommended. Treatment- Switched to UFH heparin ( acute abdomen) Steroids.

4. Investigations ( cont) MRI � B/L adrenal haemorrhage Heparin ceased LA and Antiprothrombin antibodies requested Progress � worsening ischaemic change right leg USG � right extensive DVT Haematology team consulted. TIA Significant thrombocytopenia and thrombosis noted Most likely HITT

5. Investigations =HITs Diamed - Negative ELISA � Positive Amputation planned Lepirudin Monitoring- Prolonged baseline APTT.

6. Heparin and Thrombocytopenia Heparin induced thrombocytopenia � HIT type II Isolated HIT (HIT syndrome) HIT associated thrombus (HITT) {White clot syndrome} Latent HIT { Subacute HIT} Heparin induced thrombocytopenia � HIT type I Non immune heparin associated thrombocytopenia{HAT} Pseudo HIT

7. Heparin and Thrombocytopenia