zaki
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A 65-year-old woman is admitted to the hospital with unstable angina. She is treated with isosorbide dinitrate, metoprolol, intravenous heparin, and aspirin. On the third day of hospitalization, she undergoes a diagnostic cardiac catheterization, followed by percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending coronary artery. She experiences a transient episode of atrial fibrillation the following day, converting spontaneously to sinus rhythm. The next day she complains of severe right leg pain. Physical examination shows a cool, dusky lower leg, with loss of distal pulses. There is no edema. There is also an erythematous plaque near the intravenous catheter in her left arm. Laboratory evaluation at this time is notable for a serum creatinine level of 1.1 mg/dL, a platelet count of 70,000/µL, and an activated partial thromboplastin time of 76 sec.
What is the most likely diagnosis?
A) Cholesterol crystal embolization
B) Heparin-induced thrombocytopenia
C) Femoral artery pseudoaneurysm
D) Systemic embolization due to atrial fibrillation
E) Deep venous thrombosis
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Maverick
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| mahendra
Forum Guru
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i think its D
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| alice8
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i agree so
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Dream on 'til your dream comes true.
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| zaki
Forum Guru
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try agin
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Maverick
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| guest
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B) Heparin-induced thrombocytopenia
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| mahendra
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i think its DVT
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| mahendra
Forum Guru
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please correct us.
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i will go for b
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| carla
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I will say heparin induced thrombocytopenia. :?:
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Carla
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| zaki
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well the anwere is b HIT, here is the explanation
Thrombocytopenia complicating heparin therapy comes in two forms: an early, reversible, clinically mild, nonimmune form and a less common but more severe immune-mediated thrombocytopenia. This IgG-mediated heparin-induced thrombocytopenia (HIT) may be complicated by thrombosis, acute systemic reactions following a bolus of heparin, and skin manifestations. Venous thrombosis or arterial thrombosis may occur (ratio 4:1 in favor of venous thrombosis). This is not deep venous thrombosis because the signs in this patient are those of acute arterial occlusion (loss of pulse, temperature change). A particularly severe form of venous thrombosis resulting in distal limb gangrene is associated with concomitant warfarin therapy. The time frame for development of HIT is 5 to 10 days in a previously unexposed patient, but it may occur within 24 hours if the patient has had recent exposure to heparin. This patient has thrombocytopenia, signs of arterial thrombosis, and an erythematous plaque near the site of heparin infusion, indicating HIT as the most likely diagnosis.
Cholesterol crystal embolization is a consideration given the patient’s recent cardiac catheterization, but this would present more typically with livedo reticularis and “blue toe syndrome” with preserved pulses, both of which are absent in this patient. Her renal function is preserved, although the deterioration in cholesterol crystal embolization may be slowly progressive. Thrombocytopenia is not a feature of this syndrome; eosinophilia may be seen in 50% of affected patients.
Although atrial fibrillation can result in systemic embolization, the short duration of the dysrhythmia and the fact that this patient was anticoagulated argue against this possibility; in addition, the other clinical features are not explained by this diagnosis. Femoral artery pseudoaneurysm may occur after cardiac catheterization, but distal embolization is not typically seen.
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Maverick
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