A patient with a history of
hypertension,
heart failure, and
myocardial infarction was admitted to the hospital after complaining of a two-day history of
shortness of breath, diaphoresis, and
chest pain. The patient underwent a cardiac catheterization and received several medications, including
heparin. Suspicions of HIT occurred when her platelets began to decrease severely and she developed a left groin
hematoma and a
pseudoaneurysm.
Lepirudin was initiated and a
heparin platelet factor 4 (PF4) antibody test was performed. The results were negative and
lepirudin was discontinued. She was rechallenged with
unfractionated heparin (UFH) after surgery of the
pseudoaneurysm, but her platelets began to decrease again. A second PF4 test was performed, the results of which were positive. The UFH treatment was discontinued.
Warfarin was also initiated after surgery and the patient's platelets rapidly increased after
heparin was discontinued. She was discharged one week later. Three days after discharge, she was readmitted after complaining of severe
pain and swelling of the fatty tissue of her right flank that began the day after she was discharged. Some blistering and
necrosis were noted on the lesion. Histological sections showed focal
thrombosis of vessels in the deep reticular dermis consistent with WISN. Local
wound care was given to manage the WISN,
lepirudin was initiated, and
warfarin was discontinued and reinstated one week later at a low dosage.
CONCLUSION: