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Symmetrical Peripheral Gangrene: Mechanisms for Limb Loss in the ICU in Patients With Retained Pulses. ACTA ACUST UNITED AC 2018. [DOI: 10.1097/cpm.0000000000000253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smaoui F, Koubaa M, Rekik K, Mejdoub Y, Mezghani S, Maaloul I, Hammami A, Marrakchi C, Ben Jemaa M. [Symmetrical peripheral gangrene: 4 cases]. Ann Dermatol Venereol 2018; 145:95-99. [PMID: 29169658 DOI: 10.1016/j.annder.2017.09.592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/28/2017] [Accepted: 09/26/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Symmetric peripheral gangrene (SPG) is a symmetrical distal ischemic lesion on at least 2 or more extremities in the absence of proximal arterial obstruction and vasculitis. It is a rare and severe clinical entity. The aim of this study was to describe clinical symptoms, etiological agents and the management of SPG through a series of 4 cases. PATIENTS AND METHODS We included all cases of SPG hospitalized between 2000 and 2014. The inclusion criterion was the presence of distal ischemic damage at two or more sites in the absence of large vessel obstruction. RESULTS Four patients (2 men and 2 women) were included. The mean age was 43.2±12 years. Two patients had a history of splenectomy. All patients had blackening of the tips of the fingers and toes. Three patients presented with septic shock. The etiology was bacteremia involving Streptococcus pneumoniae in two cases and a malignant form of Mediterranean spotted fever (MSF). In addition to specific antibiotics, we used a potent vasodilator (iloprost) in two cases and curative heparin therapy in two cases. The outcome was favorable in 3 cases, with regression of necrotic lesions. One case required the amputation of non-perfused necrotic fingers and toes. CONCLUSION SPG can complicate MSF in some rare cases. Thorough and repeated skin examinations are essential to ensure timely diagnosis and treatment of GPS in order to improve the prognosis.
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Affiliation(s)
- F Smaoui
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - M Koubaa
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie.
| | - K Rekik
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - Y Mejdoub
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - S Mezghani
- Laboratoire de microbiologie, université de Sfax, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - I Maaloul
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - A Hammami
- Laboratoire de microbiologie, université de Sfax, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - C Marrakchi
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - M Ben Jemaa
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
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Foead AI, Mathialagan A, Varadarajan R, Larvin M. Management of Symmetrical Peripheral Gangrene. Indian J Crit Care Med 2018; 22:870-874. [PMID: 30662227 PMCID: PMC6311972 DOI: 10.4103/ijccm.ijccm_379_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare, debilitating disease that deserves more widespread concern among the medical fraternities. The objective of this review is to outline the etiology, pathology findings, and management practices of SPG. About 18%–40% mortality rate was reported, and survivors have high frequency of multiple limb amputations. SPG is the hallmark of disseminated intravascular coagulation (DIC). The main pathogenesis theory, to date, is microthrombosis associated with disturbed procoagulant–anticoagulant balance. The treatment of SPG is largely anecdotal and theoretically involves heparin-based anticoagulation and substitution of natural anticoagulants. Early recognition, prompt management of DIC, and underlying conditions may halt the progression of the disease. The multicenter randomized controlled trial should be set up to formulate the proper treatment guidelines.
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Affiliation(s)
- Agus Iwan Foead
- Department of Orthopedics, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Amuthaganesh Mathialagan
- Department of Pharmacology, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Raghu Varadarajan
- Department of Surgery, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Michael Larvin
- Department of Surgery, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
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Zarychanski R, Houston DS. Assessing thrombocytopenia in the intensive care unit: the past, present, and future. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:660-666. [PMID: 29222318 PMCID: PMC6142536 DOI: 10.1182/asheducation-2017.1.660] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Thrombocytopenia is common among patients admitted to the intensive care unit (ICU). Multiple pathophysiological mechanisms may contribute, including thrombin-mediated platelet activation, dilution, hemophagocytosis, extracellular histones, ADAMTS13 deficiency, and complement activation. From the clinical perspective, the development of thrombocytopenia in the ICU usually indicates serious organ system derangement and physiologic decompensation rather than a primary hematologic disorder. Thrombocytopenia is associated with bleeding, transfusion, and adverse clinical outcomes including death, though few deaths are directly attributable to bleeding. The assessment of thrombocytopenia begins by looking back to the patient's medical history and presenting illness. This past information, combined with careful observation of the platelet trajectory in the context of the patient's clinical course, offers clues to the diagnosis and prognosis. Management is primarily directed at the underlying disorder and transfusion of platelets to prevent or treat clinical bleeding. Optimal platelet transfusion strategies are not defined, and a conservative approach is recommended.
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Affiliation(s)
- Ryan Zarychanski
- Division of Hematology/Medical Oncology and
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada; and
- Department of Medical Oncology & Hematology, Cancercare Manitoba, Winnipeg, MB, Canada
| | - Donald S. Houston
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada; and
- Department of Medical Oncology & Hematology, Cancercare Manitoba, Winnipeg, MB, Canada
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56
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Delabranche X, Helms J, Meziani F. Immunohaemostasis: a new view on haemostasis during sepsis. Ann Intensive Care 2017; 7:117. [PMID: 29197958 PMCID: PMC5712298 DOI: 10.1186/s13613-017-0339-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022] Open
Abstract
Host infection by a micro-organism triggers systemic inflammation, innate immunity and complement pathways, but also haemostasis activation. The role of thrombin and fibrin generation in host defence is now recognised, and thrombin has become a partner for survival, while it was seen only as one of the "principal suspects" of multiple organ failure and death during septic shock. This review is first focused on pathophysiology. The role of contact activation system, polyphosphates and neutrophil extracellular traps has emerged, offering new potential therapeutic targets. Interestingly, newly recognised host defence peptides (HDPs), derived from thrombin and other "coagulation" factors, are potent inhibitors of bacterial growth. Inhibition of thrombin generation could promote bacterial growth, while HDPs could become novel therapeutic agents against pathogens when resistance to conventional therapies grows. In a second part, we focused on sepsis-induced coagulopathy diagnostic challenge and stratification from "adaptive" haemostasis to "noxious" disseminated intravascular coagulation (DIC) either thrombotic or haemorrhagic. Besides usual coagulation tests, we discussed cellular haemostasis assessment including neutrophil, platelet and endothelial cell activation. Then, we examined therapeutic opportunities to prevent or to reduce "excess" thrombin generation, while preserving "adaptive" haemostasis. The fail of international randomised trials involving anticoagulants during septic shock may modify the hypothesis considering the end of haemostasis as a target to improve survival. On the one hand, patients at low risk of mortality may not be treated to preserve "immunothrombosis" as a defence when, on the other hand, patients at high risk with patent excess thrombin and fibrin generation could benefit from available (antithrombin, soluble thrombomodulin) or ongoing (FXI and FXII inhibitors) therapies. We propose to better assess coagulation response during infection by an improved knowledge of pathophysiology and systematic testing including determination of DIC scores. This is one of the clues to allocate the right treatment for the right patient at the right moment.
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Affiliation(s)
- Xavier Delabranche
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
| | - Julie Helms
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM, EFS Grand Est, BPPS UMR-S 949, Université de Strasbourg, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
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Shatzel JJ, Crapster-Pregont M, Deloughery TG. Non-vitamin K antagonist oral anticoagulants for heparin-induced thrombocytopenia. A systematic review of 54 reported cases. Thromb Haemost 2017; 116:397-400. [DOI: 10.1160/th16-02-0101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 03/31/2016] [Indexed: 11/05/2022]
Abstract
Supplementary Material to this article is available at www.thrombosis-online.com.
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58
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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: 280] [Impact Index Per Article: 40.0] [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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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent findings on heparin-induced thrombocytopenia (HIT), a prothrombotic disorder caused by platelet-activating IgG targeting platelet factor 4 (PF4)/polyanion complexes. RECENT FINDINGS HIT can explain unusual clinical events, including adrenal hemorrhages, arterial/intracardiac thrombosis, skin necrosis, anaphylactoid reactions, and disseminated intravascular coagulation. Sometimes, HIT begins/worsens after stopping heparin ('delayed-onset' HIT). Various HIT-mimicking disorders are recognized (e.g., acute disseminated intravascular coagulation/'shock liver' with limb ischemia). HIT has features of both B-cell and T-cell immune responses; uptake of PF4/heparin complexes into macrophages ('macropinocytosis') facilitates the anti-PF4/heparin immune response. Antibody-induced activation of monocytes and platelets via their FcγIIA receptors triggers an intense procoagulant response. Sometimes, HIT antibodies recognize PF4 bound to (platelet-associated) chondroitin sulfate, explaining how HIT might occur without concurrent or recent heparin (delayed-onset HIT, 'spontaneous HIT syndrome'). The molecular structure of HIT antigen(s) has been characterized, providing a rationale for future drug design to avoid HIT and improve its treatment. The poor correlation between partial thromboplastin time and plasma argatroban levels (risking subtherapeutic anticoagulation) and need for intravenous administration of argatroban have led to increasing 'off-label' treatment with fondaparinux or one of the direct oral anticoagulants. SUMMARY Understanding the molecular mechanisms and unusual clinical features of HIT will improve its management.
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60
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Colling ME, Bendapudi PK. Purpura Fulminans: Mechanism and Management of Dysregulated Hemostasis. Transfus Med Rev 2017; 32:69-76. [PMID: 29157918 DOI: 10.1016/j.tmrv.2017.10.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/21/2017] [Accepted: 10/13/2017] [Indexed: 01/30/2023]
Abstract
Purpura fulminans (PF) is a highly thrombotic subtype of disseminated intravascular coagulation that can accompany severe bacterial, and more rarely, viral infections. PF is associated with an extremely high mortality rate, and patients often die of overwhelming multisystemic thrombosis rather than septic shock. Survivors typically experience amputation of involved extremities and significant scarring in affected areas. Despite the devastating clinical course associated with this hemostatic complication of infection, the mechanism of PF remains poorly understood. Severe acquired deficiency of protein C and dysfunction of the protein C-thrombomodulin pathway as well as other systems that exert a negative regulatory effect on coagulation have been implicated. Management of PF involves treatment of the underlying infection, aggressive anticoagulation, and robust transfusion support aimed at correcting acquired deficiencies in natural anticoagulant proteins. In this review, we address the diagnosis and management of PF with a focus on a rational approach to this condition informed by the available data. Proposed mechanisms underlying the dysregulation of coagulation seen in PF are also covered, and implications for therapy are discussed.
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Affiliation(s)
- Meaghan E Colling
- Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Pavan K Bendapudi
- Harvard Medical School, Boston, MA; Division of Hematology, Massachusetts General Hospital, Boston, MA; Blood Transfusion Service, Massachusetts General Hospital, Boston, MA.
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Padmanabhan A, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Irani MS, Bryant BJ, Alperin JB, Deloughery TG, Mulvey KP, Dhakal B, Wen R, Wang D, Aster RH. IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia. Chest 2017; 152:478-485. [PMID: 28427966 DOI: 10.1016/j.chest.2017.03.050] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) complicated by severe thrombocytopenia and thrombosis can pose significant treatment challenges. Use of alternative anticoagulants in this setting may increase bleeding risks, especially in patients who have a protracted disease course. Additional therapies are lacking in this severely affected patient population. METHODS We describe three patients with HIT who had severe thromboembolism and prolonged thrombocytopenia refractory to standard treatment but who achieved an immediate and sustained response to IVIg therapy. The mechanism of action of IVIg was evaluated in these patients and in five additional patients with severe HIT. The impact of a common polymorphism (H/R 131) in the platelet IgG receptor FcγRIIa on IVIg-mediated inhibition of platelet activation was also examined. RESULTS At levels attained in vivo, IVIg inhibits HIT antibody-mediated platelet activation. The constant domain of IgG (Fc) but not the antigen-binding portion (Fab) is required for this effect. Consistent with this finding, IVIg had no effect on HIT antibody binding in a solid-phase HIT immunoassay (platelet factor 4 enzyme-linked immunoassay). The H/R131 polymorphism in FcγRIIa influences the susceptibility of platelets to IVIg treatment, with the HH131 genotype being most susceptible to IVIg-mediated inhibition of antibody-induced activation. However, at high doses of IVIg, activation of platelets of all FcγRIIa genotypes was significantly inhibited. All three patients did well on long-term anticoagulation therapy with direct oral anticoagulants. CONCLUSIONS These studies suggest that IVIg treatment should be considered in patients with HIT who have severe disease that is refractory to standard therapies.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI.
| | - Curtis G Jones
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, WI
| | - Daniel W Bougie
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Mehraboon S Irani
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Barbara J Bryant
- Department of Pathology, University of Texas Medical Branch, Galveston, TX
| | - Jack B Alperin
- Department of Pathology, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - Kevin P Mulvey
- Department of Medicine, Kootenai Health, Coeur d'Alene, ID
| | - Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Renren Wen
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Richard H Aster
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Shapiro RM, Zeller MP, Warkentin TE. Sepsis and persisting neutropenia in a drug addict. Am J Hematol 2017; 92:312-316. [PMID: 28052478 DOI: 10.1002/ajh.24639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/02/2016] [Accepted: 12/31/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Roman M. Shapiro
- Department of MedicineLondon Health Science CentreLondon Ontario Canada
| | - Michelle P. Zeller
- Department of Pathology and Molecular MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
- Department of MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
| | - Theodore E. Warkentin
- Department of Pathology and Molecular MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
- Department of MedicineMichael G. DeGroote School of Medicine, McMaster UniversityHamilton Ontario Canada
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Rijal G, Kim BS, Pati F, Ha DH, Kim SW, Cho DW. Robust tissue growth and angiogenesis in large-sized scaffold by reducing H
2
O
2
-mediated oxidative stress. Biofabrication 2017; 9:015013. [DOI: 10.1088/1758-5090/9/1/015013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Thachil J, Warkentin TE. How do we approach thrombocytopenia in critically ill patients? Br J Haematol 2016; 177:27-38. [PMID: 27982413 DOI: 10.1111/bjh.14482] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A low platelet count is a frequently encountered haematological abnormality in patients treated in intensive treatment units (ITUs). Although severe thrombocytopenia (platelet count <20 × 109 /l) can be associated with bleeding, even moderate-degree thrombocytopenia is associated with organ failure and adverse prognosis. The aetiology for thrombocytopenia in ITU is often multifactorial and correcting one aetiology may not normalise the low platelet count. The classical view for thrombocytopenia in this setting is consumption associated with thrombin-mediated platelet activation, but other concepts, including platelet adhesion to endothelial cells and leucocytes, platelet aggregation by increased von Willebrand factor release, red cell damage and histone release, and platelet destruction by the complement system, have recently been described. The management of severe thrombocytopenia is platelet transfusion in the presence of active bleeding or invasive procedure, but the risk-benefit of prophylactic platelet transfusions in this setting is uncertain. In this review, the incidence and mechanisms of thrombocytopenia in patients with ITU, its prognostic significance and the impact on organ function is discussed. A practical approach based on the authors' experience is described to guide management of a critically ill patient who develops thrombocytopenia.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Warkentin TE, Pai M. Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis: reply. J Thromb Haemost 2016; 14:2317-2319. [PMID: 27608440 DOI: 10.1111/jth.13498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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66
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Warkentin TE. Clinical picture of heparin-induced thrombocytopenia (HIT) and its differentiation from non-HIT thrombocytopenia. Thromb Haemost 2016; 116:813-822. [PMID: 27656712 DOI: 10.1160/th16-06-0435] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/12/2016] [Indexed: 12/14/2022]
Abstract
HIT is an acquired antibody-mediated disorder strongly associated with thrombosis, including microthrombosis secondary to disseminated intravascular dissemination (DIC). The clinical features of HIT are reviewed from the perspective of the 4Ts scoring system for HIT, which emphasises its characteristic timing of onset of thrombocytopenia. HIT antibodies recognize multimolecular complexes of platelet factor 4 (PF4)/heparin. However, a subset of HIT sera recognise PF4 bound to platelet chondroitin sulfate; these antibodies activate platelets in vitro and in vivo even in the absence of heparin, thus explaining: delayed-onset HIT (where HIT begins or worsens after stopping heparin); persisting HIT (where HIT takes several weeks to recover); spontaneous HIT syndrome (a disorder clinically and serologically resembling HIT but without proximate heparin exposure); and fondaparinux-associated HIT (four distinct syndromes featuring thrombocytopenia that begins or worsens during treatment with fondaparinux), with a new patient case presented with ongoing thrombocytopenia (and fatal haemorrhage) during treatment of HIT with fondaparinux, with fondaparinux-dependent platelet activation induced by patient serum ("fondaparinux cross-reactivity"). Ironically, despite existence of fondaparinux-associated HIT, this pentasaccharide anticoagulant is a frequent treatment for HIT (including one used by the author). HIT can be confused with other disorders, including those with a) timing similar to HIT (e. g. abciximab-associated thrombocytopenia of delayed-onset); b) combined thrombocytopenia/thrombosis (e. g. symmetrical peripheral gangrene secondary to acute DIC and shock liver); and c) both timing of onset and thrombosis (e. g. warfarin-associated venous limb gangrene complicating cancer-associated DIC). By understanding clinical and pathophysiological similarities and differences between HIT and non-HIT mimicking disorders, the clinician is better able to make the correct diagnosis.
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Affiliation(s)
- Theodore E Warkentin
- Prof. Theodore (Ted) E. Warkentin, Hamilton Regional Laboratory Medicine Program, Room 1-270B, Hamilton General Hospital, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada, Tel.: +1 905 527 0271 ext. 46139, Fax: +1 905 577 1421, E-mail:
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Abstract
PURPOSE OF REVIEW Thrombocytopenia and heparin exposure are common in critically ill patients, yet immune heparin-induced thrombocytopenia (HIT), a prothrombotic adverse effect of heparin, rarely accounts for thrombocytopenia in this patient population. The review discusses the clinical and laboratory features that distinguish HIT from non-HIT thrombocytopenia. RECENT FINDINGS The frequency of HIT in heparin-exposed critically ill patients is approximately 0.3-0.5% versus at least a 30-50% background frequency of non-HIT thrombocytopenia. Most patients who form anti-PF4/heparin antibodies do not develop HIT, contributing to HIT overdiagnosis. Disseminated intravascular coagulation (DIC), particularly in the setting of cardiogenic or septic shock associated with 'shock liver', can cause ischemic limb gangrene with pulses, mimicking a clinical picture of HIT. However, whereas non-HIT-related DIC with microthrombosis can be treated with heparin, HIT usually requires nonheparin anticoagulation. HIT-associated DIC can result in an elevated INR, which could reflect factor VII depletion because of extrinsic (tissue factor) pathway-mediated activation of coagulation. SUMMARY Greater understanding of the various clinical and laboratory features that distinguish HIT from non-HIT thrombocytopenia could help improve outcomes in patients who develop thrombocytopenia and coagulopathies in the ICU.
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Pinto-Lopes P, von Hafe P. A fatal case of upper-extremity deep vein thrombosis. Porto Biomed J 2016; 1:124-125. [DOI: 10.1016/j.pbj.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022] Open
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Scully M, Gates C, Neave L. How we manage patients with heparin induced thrombocytopenia. Br J Haematol 2016; 174:9-15. [PMID: 27097741 DOI: 10.1111/bjh.14102] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heparin induced thrombocytopenia (HIT) remains a rare, but significant, condition related to mortality and morbidity. The incidence has decreased with reduced use of unfractionated heparin, with the exception of cardiac surgery. Due to the high risk of thrombosis, a switch to a non-heparin anticoagulant is required, until platelet counts normalize. Within the acute setting, argatroban, fondaparinux and direct acting oral anticoagulants (DOACS) are therapeutic options. In patients with HIT-associated thrombosis or who require long-term anticoagulation, warfarin remains the preference, but DOACs are attractive alternatives.
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Affiliation(s)
- Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK
| | - Carolyn Gates
- Thrombosis and Anticoagulant Pharmacist, University College London Hospital, London, UK
| | - Lucy Neave
- Specialist Registrar, Department of Haematology, UCLH, London, UK
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Rickles FR, Brenner B, Falanga A. The International Conference on Thrombosis and Hemostasis Issues in Cancer (ICTHIC) at the Peak of Adolescence - 15 Years and Counting. Thromb Res 2016; 140 Suppl 1:S99-102. [PMID: 27067988 DOI: 10.1016/s0049-3848(16)30107-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Frederick R Rickles
- The Departments of Medicine, Pediatrics and Pharmacology and Physiology, The Dr. Cyrus & Myrtle Katzen Cancer Research Center, The George Washington University and the Veterans Administration Medical Center, Washington, DC, USA.
| | - Benjamin Brenner
- Thrombosis and Hemostasis Unit, Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Anna Falanga
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Warkentin TE, Pai M. Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis? J Thromb Haemost 2016; 14:231-5. [PMID: 26662371 DOI: 10.1111/jth.13219] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/25/2015] [Indexed: 11/29/2022]
Abstract
For unknown reasons, a small minority of critically ill patients with septic or cardiogenic shock, multiorgan failure, and disseminated intravascular coagulation develop symmetrical acral (distal extremity) limb loss due to microvascular thrombosis ('limb gangrene with pulses'). Case reports have described preceding 'shock liver' in some critically ill patients who developed such a picture of ischemic limb necrosis. This suggests that profoundly disturbed procoagulant-anticoagulant balance featuring uncontrolled generation of thrombin-resulting from failure of the protein C and antithrombin natural anticoagulant systems due to insufficient hepatic synthesis of these crucial proteins-could explain the microvascular thrombosis and associated limb loss. We hypothesize that shock liver is the key predisposing risk factor underlying ischemic limb necrosis in the majority of patients who develop this complication in the setting of acute disseminated intravascular coagulation complicating septic or cardiogenic shock. As shock liver precedes onset of limb ischemia by several days, therapeutic intervention may be possible.
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Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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