ssrpk
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A 58-year-old woman is having persistent heavy bleeding from her surgical wound following a mastectomy for carcinoma of breast. Purpura of her arms and truck are noted. Urine output has been only 300 mL in 24 hours. Laboratory studies show hemoglobin 9 gm/dL, white blood cells 16,500/mm3, with 75% polymorphonuclear leukocytes and 12% bands, and platelets 55,000/mm3. Serum urea nitrogen (BUN) is 35 mg/dL, creatinine is 2.8 mg/dL. Coagulation studies reveal a prothrombin time of 18 seconds and an activated partial thromboplastin time of 50 seconds. Fibrinogen is 150 mg/dL, thrombin time is prolonged, fibrin degradation products are 30 micrograms/dL (normal <10), D-Dimer is 600 micrograms/L (normal <250). Urinalysis shows numerous red cells in the sediment. Which of the following is the most likely diagnosis?
A) Disseminated intravascular coagulation (DIC)
B) Dysfibrinogenemia
C) Hemolytic uremic syndrome
D) Idiopathic thrombocytopenic purpura (ITP)
E) Inadequate surgical hemostasis, with consumption of clotting factors due to hemorrhage
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| Natasa
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A?
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| Natasa
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It could be DIC due to sepsis,what do you all say?
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| druas
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well could be A or C...DIC resulting in Diffuse cortical necrosis...FDP and d dimers...
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| druas
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i dont think we see FDP in HUS....
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| anjushree
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i will go with DIC
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| Natasa
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HemolythicUremicSyndrome is more common in kids-under 10 and without a history of a major surgery.And if it was HUS she should have bloody diarhea as well,right?
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| krsna
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its A guys...why did C come in here!!!
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| drk1980
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i closed my eyes and marked DIC...
but knowing who the Q poster is.....there has to be a twist in it!!!
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| sturge_weber
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yes me too, if it were in exam i would mark dic,
but ssrpk , our guru, has posted it, so i also stand with drk...
there has to be some catch out here
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| reet
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ya,,, some mystery ther
i would go with B........
DYFIBROGENEMIA--- cuz some defect in fibrinogen production might be lead to thrombosis....
Edited by reet on 01/31/06 - 12:08 PM
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| icefires
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I would say A.
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| msyamp
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It very nearly corresponds with DIC. HUS occurs in children and cnaaot have elevated d-dimer.
I wolld go with DIC. consumption of clotting factors cannot directly lead to renal manifestations.
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| yoga
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intersting mcq but the mystery hasnt been solved!!
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| new_n_lost
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I wud go for ITP cos D dimer and FDPs can also be elevated due to recent surgery cos the rest of picture fits with ITP.
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| ssrpk
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wow, hahah, that was interesting discussion. besides i don't remember posting this question at all, but i might have saved somethng interestng out of it in my archives, because it looks like dic, and the reason is none other would increase PT and APTT, and PT APTT don't usually increase post-operatively
and yeah nnl, d-dimer and FDPs are merely a distractor, if you think through.
i will check it out
also ITP wouldn't give us red blood cells urinary sediments
i will go with DIC, but i gotta check, because i have made it really fishy
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| Ujk
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A
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| new_n_lost
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ssrpk wrote:
wow, hahah, that was interesting discussion. besides i don't remember posting this question at all, but i might have saved somethng interestng out of it in my archives, because it looks like dic, and the reason is none other would increase PT and APTT, and PT APTT don't usually increase post-operatively
and yeah nnl, d-dimer and FDPs are merely a distractor, if you think through.
i will check it out
also ITP wouldn't give us red blood cells urinary sediments
i will go with DIC, but i gotta check, because i have made it really fishy
Yup A picture of DIC does seem convincing cos the Renal outcome is not explained by ITP. Then we r left with HUS which can also present in adults (its not exclusive to children) but doesnt have the associated Coagulation profile. Even if we do consider FDPs and D-dimer results as distractors ( a recent surgery tends to increase both ref: NEJM) none of the choices explain the complete picture which is presented. Lets say this is early DIC.
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| SmokyWaters
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A
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