Thrombosis with Thrombocytopenia - A Vascular Paradox

BACKGROUND Thrombosis associated with thrombocytopenia is a vascular paradox which we seldom encounter in our clinical practice. We hereby describe four real world clinical situations and their therapeutic management. Since there are no guidelines regarding this subset, most of the treatment is based on few anecdotal reports and consensus data. Hence, we have reviewed the literature to throw light on some pertinent clinically relevant questions. Our objective is to describe and discuss the probable reasons of vascular paradox and its management. METHODS It is a descriptive study of four cases collected over one-year period including patients of thrombosis with thrombocytopenia. RESULTS In the first case, the patient had pulmonary embolism as a presenting manifestation of leukaemia. Only 5 % cases of AML-M3 sub type acute promyelocytic leukaemia present with normal peripheral blood smear. Patient had thrombocytopenia with deep vein thrombosis and pulmonary embolism. In the second case, secondary antiphospholipid antibody syndrome (APLS) presented with ilio-femoral deep vein thrombosis associated with thrombocytopenia and bleeding tendency. In the third case, antiphospholipid antibody syndrome with thrombocytopenia was associated with severe pulmonary hypertension and deep vein thrombosis. In the fourth case, patient presented with non-ST elevation myocardial infarction (NSTEMI) with thrombocytopenia. He was diagnosed with idiopathic thrombocytopenic purpura. He had angiographic evidence of critical triple vessel disease. He was treated with coronary bypass surgery after initiating treatment with oral eltrombopag and steroids. CONCLUSIONS We have highlighted four clinical situations ranging from frank malignancy to pure vascular pathology, where we have encountered and tackled the vascular paradox of ‘thrombosis and thrombocytopenia’ and reviewed the literature pertaining to these case scenarios. KEYWORDS Thrombosis with Thrombocytopenia, APLS, AML-M3, Pulmonary Hypertension, ITP

The impact of thrombosis and bleeding among patients with Myeloproliferative Neoplasm: Systematic Review and Meta Analysis.

Background: Thrombosis and bleeding are the most common complications which contribute to significant morbidity and mortality of myeloproliferative patients. This study aimed to find out the incidence of thrombotic and bleeding events during diagnosis and follow up among patients with myeloproliferative neoplasm. This might help in the early detection of thrombosis and bleeding and prevention of such complications for MPN patients. Methods: A systematic review and meta-analysis was conducted to assess the incidence of thrombosis and bleeding. Data extracted from the literatures in Google scholars, Mendeley, PubMed, and EMBASE databases. Studies that had thrombosis and/or bleeding reports with any types of myeloproliferative neoplasm were included in this study. We used random effect model to estimate the odd ratio, relative risk and risk difference with 95%CI of each studies and the pooled results based on Cochrane methods of Revman. A funnel plot and I2 test checked to see the publication bias and heterogeneity respectively. Results: Nineteen studies with 14706 participants that had fitted the inclusion criteria were included in the overall thrombosis study. Five studies (n=931) included for incidence thrombosis at diagnosis and follow up. The pooled overall frequency thrombosis was 18.6%. The pooled incidence of thrombosis at diagnosis was 26.5% and odds ratio (OR= 3.17,95%CI 0.96 to10.43); relative risk (RR= 2.07,95%CI 0.98 to 4.34); risk difference (RD=21%, 95%CI -0.05 to 0.48, high certainty). Thrombosis had significant differences during diagnosis and follow up. A history of thrombosis, age >60years, and smoking were some of the risk factors for thrombosis. Conclusions: Based on the findings, thrombosis and bleeding are the highest complications occurred among myeloproliferative neoplasm patients. This problem is also common both during diagnosis and follow up of MPN patients. Early detection and follow up is needed to prevent MPN complications. Keywords: Thrombosis, bleeding, MPN, diagnosis, follow up.

Coagulation Disorders

There are multiple congenital and acquired disorders of coagulation that may result in unplanned bleeding or clotting. These disorders can result in an increase in morbidity and mortality to surgical patients. Unexpected bleeding during and after surgery can be prevented by having an adequate understandings of these entities and by being aware of the available treatment options. In addition to awareness of bleeding disorders, it is important to recognize the risks associated with disorders predisposing patients to clotting, or thrombophilias. This review discusses the major inherited disorders of the coagulation cascade resulting in bleeding or clotting tendencies in relation to surgical patients. von Willebrand Disease (vWD), hemophilia A, hemophilia B, hemophilia C, acute coagulopathy of trauma, disseminated intravascular coagulation (DIC), uremic bleeding, bleeding in cirrhosis, clotting disorders, and acquired thrombophilias are covered. This review 4 figures, 25 tables, and 47 references. Keywords: Thrombosis, bleeding, coagulation, disseminated intravascular coagulation, factor deficiency, factor V Leiden, von Willebrand disease, thrombophilia, clotting, hemophilia