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Zyani A, Elyachioui K, Treyi C, Aabdi M, Sbai H. A rare case of intracerebral hemorrhage complicating heparin-induced thrombocytopenia in a COVID-19 patient. Ann Med Surg (Lond) 2021; 72:103070. [PMID: 34840776 PMCID: PMC8605820 DOI: 10.1016/j.amsu.2021.103070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Heparin-induced thrombocytopenia is a rare complication of heparin therapy associated with thrombocytopenia and mainly thrombotic complications. Case report we herein describe a case of a woman hospitalized for management of a severe case of COVID-19 treated with low molecular weight heparin, who developed heparin-induced thrombocytopenia complicated by intracerebral hemorrhage with no thrombotic complications. Conclusion Discontinuation of heparin was effective without the use of other non-heparin anticoagulants, platelet transfusion or plasmapheresis. HIT is a rare complication of LMWH, it is associated with thrombocytopenia and mainly thrombotic complications. In this paper we will report a rare complication of HIT : ICH in a 63 years old woman admitted for covid 19-infection. Discontinuation of heparin was effective without the use of other non-heparin anticoagulants, platelet transfusion or plasmapheresis.
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Affiliation(s)
- A Zyani
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - K Elyachioui
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - C Treyi
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - M Aabdi
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - H Sbai
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Onwuemene OA. Bleeding is associated with intravenous immunoglobulin and therapeutic plasma exchange use in heparin‐induced thrombocytopenia: A propensity matched analysis. EJHAEM 2021; 2:466-470. [PMID: 35844687 PMCID: PMC9175867 DOI: 10.1002/jha2.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023]
Abstract
Intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE) are used in select cases with heparin‐induced thrombocytopenia (HIT). In a cross‐sectional analysis, a propensity matched sample was generated by IVIG or TPE treatment status to assess the primary outcome of mortality. In 500 HIT cases, IVIG or TPE was not associated with increased mortality (OR = 1.46; 95% CI: 0.81–2.63, p = 0.2052) but was associated with a higher likelihood of major bleeding (OR = 1.75; 95% CI: 1.03–2.96, p = 0.0376). The use of IVIG or TPE in HIT cases with bleeding contraindications to standard therapies should be further investigated.
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Affiliation(s)
- Alexandre Soares Ferreira Júnior
- School of Medicine Barretos School of Health Sciences Dr. Paulo Prata Barretos São Paulo Brazil
- Department of Medicine Faculdade de Medicina de São José do Rio Preto (FAMERP) São José do Rio Preto São Paulo Brazil
| | | | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics Duke University School of Medicine Durham North Carolina USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology Department of Medicine Duke University School of Medicine Durham North Carolina USA
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A population-based analysis on the use of therapeutic plasma exchange and intravenous immunoglobulin in heparin-induced thrombocytopenia. Thromb Res 2021; 201:6-14. [PMID: 33621860 DOI: 10.1016/j.thromres.2021.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/30/2020] [Accepted: 02/08/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION In heparin-induced thrombocytopenia (HIT), selected patients are treated with therapies directed at the immune response, intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE). To determine IVIG and TPE characteristics and outcomes in HIT, we analyzed the National Inpatient Sample (NIS) database. METHODS In a population-based analysis of the NIS, we identified hospital discharges of adult patients with a HIT diagnosis. A two-level statistical analysis was performed comparing cases as follows 1) IVIG or TPE vs. none; and 2) IVIG vs. TPE. For each analysis, the primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, infections, hospital length of stay, and total charges. RESULTS Among 22,152 discharges with a HIT diagnosis, 77 (0.34%) and 52 (0.23%) received TPE and IVIG, respectively. In the first level analysis of TPE or IVIG vs. no treatment, TPE or IVIG treatment was associated with a higher likelihood of in-hospital mortality (OR = 1.85; 95%CI: 1.13-3.03, p = 0.0104), major bleeding (OR = 1.91; 95%CI: 1.25-2.93, p = 0.0030), gastrointestinal bleeding (OR = 1.89; 95%CI: 1.08-3.30, p = 0.0259), and infection (OR = 1.65; 95% CI:1.13-2.41, p = 0.0095). In the second-level analysis comparing IVIG vs. TPE, there were no significant differences in patient characteristics or outcomes in both unadjusted and adjusted analyses. CONCLUSIONS In this population-based analysis of HIT, we found similar outcomes of IVIG and TPE-treated cases. Given the small sample size, future studies are needed to confirm this observation.
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Heparin-Induced Thrombocytopenia: A Review of New Concepts in Pathogenesis, Diagnosis, and Management. J Clin Med 2021; 10:jcm10040683. [PMID: 33578859 PMCID: PMC7916628 DOI: 10.3390/jcm10040683] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/17/2022] Open
Abstract
Knowledge on heparin-induced thrombocytopenia keeps increasing. Recent progress on diagnosis and management as well as several discoveries concerning its pathogenesis have been made. However, many aspects of heparin-induced thrombocytopenia remain partly unknown, and exact application of these new insights still need to be addressed. This article reviews the main new concepts in pathogenesis, diagnosis, and management of heparin-induced thrombocytopenia.
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Akinyemiju T, Onwuemene OA. Use of therapeutic plasma exchange in heparin-induced thrombocytopenia: A population-based study. J Clin Apher 2021; 36:398-407. [PMID: 33453132 DOI: 10.1002/jca.21876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is characterized by anti-heparin/platelet factor 4 immune complexes, which are removed by therapeutic plasma exchange (TPE). Our main objective was to study TPE outcomes in HIT using a large administrative claims database. STUDY DESIGN AND METHODS We used the National Inpatient Sample (NIS) to identify hospital discharges of adult patients (≥18) with a primary or secondary diagnosis of HIT. Cases were classified into two groups based on TPE use. The primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, hospital length of stay (LOS), and charges. Multivariable regression analysis, controlling for age and medical comorbidities, was used to examine the association of TPE with study outcomes. RESULTS A HIT diagnosis was made in 22 165 discharges, of which 90 (0.4%) received TPE. Corresponding national estimates are 106 435 and 439, respectively. TPE was not associated with decreased in-hospital mortality (OR = 1.72; 95%CI: 0.93-3.17, P = .085). However, TPE was associated with a higher likelihood of major bleeding (OR = 2.35; 95%CI: 1.40-3.68, P = .0009), primarily driven by gastrointestinal bleeding (OR = 2.21; 95%CI: 1.17-4.17, P = .015). TPE was also associated with higher hospital LOS (20.5 vs 10 day, P < .0001) and charges (USD 211181 vs USD 81654, P < .0001). CONCLUSION TPE's association with increased bleeding and a prolonged hospital course indicates that it is being used in HIT cases with a severe clinical phenotype. Future studies are needed to better characterize the HIT phenotype that will most benefit from TPE.
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Affiliation(s)
| | - Stephen H Boyle
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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MIYAUCHI T, SAGA I, KOJIMA A. Acute Subdural Hematoma Complicating Heparin-induced Thrombocytopenia: A Case Report. NMC Case Rep J 2021; 8:799-803. [PMID: 35079551 PMCID: PMC8769446 DOI: 10.2176/nmccrj.cr.2021-0262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated drug reaction to heparin use that causes platelet aggregation, followed by thrombocytopenia. Despite the thrombocytopenia, the main complications of HIT are thromboembolic in nature rather than hemorrhagic, and in particular, intracranial hemorrhage is rare. Herein, we describe a case of atraumatic acute subdural hematoma secondary to HIT, which was treated by platelet transfusion and surgery. A 77-year-old woman was admitted to our hospital for the treatment of severe aortic valve stenosis. Unfractionated heparin was administered during the preoperative period and during the aortic valve replacement surgery. Three days after the cardiac surgery, the patient presented with coma consistent with an acute subdural hematoma in the posterior fossa and obstructive hydrocephalus. Laboratory examination revealed a marked decrease of the platelet count to 40000/µL, and subsequent serological assay confirmed the diagnosis of HIT. The patient was treated by transfusion of platelets and fresh frozen plasma, and surgical removal of the hematoma. We started the administration of argatroban for substitution of heparin 4 days after the craniotomy. On day 13 after the neurosurgery, the patient developed cerebral infarction due to left middle cerebral artery occlusion and persistent right hemiparesis. We presented a rare case of the patient who developed acute subdural hematoma complicating HIT. Emergency craniotomy was successfully performed after administering platelet transfusions. Our experience with the present case suggests that platelet transfusions may be effective for performing emergency surgery for intracranial hemorrhage, even in patients with HIT.
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Affiliation(s)
- Tsubasa MIYAUCHI
- Department of Neurosurgery, Saitama City Hospital, Saitama, Saitama, Japan
| | - Isako SAGA
- Department of Neurosurgery, Saitama City Hospital, Saitama, Saitama, Japan
| | - Atsuhiro KOJIMA
- Department of Neurosurgery, Saitama City Hospital, Saitama, Saitama, Japan
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Greinacher A, Selleng K, Warkentin TE. Autoimmune heparin-induced thrombocytopenia. J Thromb Haemost 2017; 15:2099-2114. [PMID: 28846826 DOI: 10.1111/jth.13813] [Citation(s) in RCA: 272] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Indexed: 01/18/2023]
Abstract
Autoimmune heparin-induced thrombocytopenia (aHIT) indicates the presence in patients of anti-platelet factor 4 (PF4)-polyanion antibodies that are able to activate platelets strongly even in the absence of heparin (heparin-independent platelet activation). Nevertheless, as seen with serum obtained from patients with otherwise typical heparin-induced thrombocytopenia (HIT), serum-induced platelet activation is inhibited at high heparin concentrations (10-100 IU mL-1 heparin). Furthermore, upon serial dilution, aHIT serum will usually show heparin-dependent platelet activation. Clinical syndromes associated with aHIT include: delayed-onset HIT, persisting HIT, spontaneous HIT syndrome, fondaparinux-associated HIT, heparin 'flush'-induced HIT, and severe HIT (platelet count of < 20 × 109 L-1 ) with associated disseminated intravascular coagulation (DIC). Recent studies have implicated anti-PF4 antibodies that are able to bridge two PF4 tetramers even in the absence of heparin, probably facilitated by non-heparin platelet-associated polyanions (chondroitin sulfate and polyphosphates); nascent PF4-aHIT-IgG complexes recruit additional heparin-dependent HIT antibodies, leading to the formation of large multimolecular immune complexes and marked platelet activation. aHIT can persist for several weeks, and serial fibrin, D-dimer, and fibrinogen levels, rather than the platelet count, may be helpful for monitoring treatment response. Although standard anticoagulant therapy for HIT ought to be effective, published experience indicates frequent failure of activated partial thromboplastin time (APTT)-adjusted anticoagulants (argatroban, bivalirudin), probably because of underdosing in the setting of HIT-associated DIC, known as 'APTT confounding'. Thus, non-APTT-adjusted therapies with drugs such as danaparoid and fondaparinux, or even direct oral anticoagulants, such as rivaroxaban or apixaban, are suggested therapies, especially for long-term management of persisting HIT. In addition, emerging data indicate that high-dose intravenous immunoglobulin can interrupt HIT antibody-induced platelet activation, leading to rapid platelet count recovery.
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MESH Headings
- Administration, Oral
- Animals
- Anticoagulants/administration & dosage
- Anticoagulants/adverse effects
- Anticoagulants/immunology
- Autoantibodies/blood
- Autoimmunity/drug effects
- Blood Coagulation/drug effects
- Blood Platelets/drug effects
- Blood Platelets/immunology
- Blood Platelets/metabolism
- Heparin/adverse effects
- Heparin/immunology
- Humans
- Immunoglobulins, Intravenous/administration & dosage
- Immunologic Factors/administration & dosage
- Partial Thromboplastin Time
- Platelet Activation/drug effects
- Platelet Factor 4/immunology
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
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Affiliation(s)
- A Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - K Selleng
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, Department of Medicine, and McMaster Centre for Transfusion Research, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality. Blood 2015; 125:1470-6. [PMID: 25588677 DOI: 10.1182/blood-2014-10-605493] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
While platelets are primary mediators of hemostasis, there is emerging evidence to show that they may also mediate pathologic thrombogenesis. Little data are available on risks and benefits associated with platelet transfusions in thrombotic thrombocytopenic purpura (TTP), heparin-induced thrombocytopenia (HIT) and immune thrombocytopenic purpura (ITP). This study utilized the Nationwide Inpatient Sample to evaluate the current in-hospital platelet transfusion practices and their association with arterial/venous thrombosis, acute myocardial infarction (AMI), stroke, and in-hospital mortality over 5 years (2007-2011). Age and gender-adjusted odds ratios (adjOR) associated with platelet transfusions were calculated. There were 10 624 hospitalizations with TTP; 6332 with HIT and 79 980 with ITP. Platelet transfusions were reported in 10.1% TTP, 7.1% HIT, and 25.8% ITP admissions. Platelet transfusions in TTP were associated with higher odds of arterial thrombosis (adjOR = 5.8, 95%CI = 1.3-26.6), AMI (adjOR = 2.0, 95%CI = 1.2-3.3) and mortality (adjOR = 2.0,95%CI = 1.3-3.0), but not venous thrombosis. Platelet transfusions in HIT were associated with higher odds of arterial thrombosis (adjOR = 3.4, 95%CI = 1.2-9.5) and mortality (adjOR = 5.2, 95%CI = 2.6-10.5) but not venous thrombosis. Except for AMI, all relationships remained significant after adjusting for clinical severity and acuity. No associations were significant for ITP. Platelet transfusions are associated with higher odds of arterial thrombosis and mortality among TTP and HIT patients.
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Plasmapheresis May Be an Option in Urgent Management of Heparin-Induced Thrombocytopenia in the Setting of Acute Intracerebral Hemorrhage. Neurocrit Care 2014; 22:140-5. [DOI: 10.1007/s12028-014-0052-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chan KM, Cheung CY, Chau KF. Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient: A case report. Hemodial Int 2014; 18:555-8. [DOI: 10.1111/hdi.12137] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Koon Ming Chan
- Department of Medicine; Queen Elizabeth Hospital; Hong Kong
| | | | - Ka Foon Chau
- Department of Medicine; Queen Elizabeth Hospital; Hong Kong
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Refractoriness to platelet transfusion in acute myeloid leukemia correlated with the optical density of anti-platelet factor 4/heparin antibodies. Int J Hematol 2013; 98:472-7. [DOI: 10.1007/s12185-013-1427-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 08/30/2013] [Accepted: 09/02/2013] [Indexed: 12/28/2022]
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