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CLOTTINGTESTS. MKSAP-Q1. . 80 yr man3 week h/o massive bruisingon no meds; FH negativeLabs: platelets 350,000 PT 12 sec; aPTT 78 sec; Bleeding time: 6 min fibrinogen 390 g/dL; D-dimer: 1000 ng/mL aPTT 1:1 mix: 71 sec LFTs normal. Q: Dx?. acquired F VIII inhibitor DIC LA Factor XII deficiency chronic liver disease.
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1. Board Review
3. MKSAP-Q1 80 yr man
3 week h/o massive bruising
on no meds; FH negative
Labs: platelets 350,000 PT 12 sec; aPTT 78 sec; Bleeding time: 6 min fibrinogen 390 g/dL; D-dimer: 1000 ng/mL aPTT 1:1 mix: 71 sec LFTs normal
4. Coag tests – MKSAP-Q2 32 yr man; hematemesis x 2 h
Strict vegetarian diet x 4 weeks for weight control and abstained from alcohol for same period of time
PE: pale, spleen 3 cm enlarged; liver not palpable
Hbg 8.0; MCV 85; WBC 10; plts 75,000
PT 28 sec; aPTT 50 sec; BT 7.5 min; fibrinogen 165 mg/dL
Albumin 2.0; ASAT 75; ALAT 45
PT 1:1 mix: 12 sec; aPTT 1:1 mix: 30 sec
5. MKSA-Q3 46 yr man post CABG
On heparin DVT prophylaxis 5000 U q 12
Day 4 post-op right calf swelling and pain – Doppler-US: DVT
plts 75,000
6. Heparin induced thrombocytopenia HIT (HIT-1, HIT-2, HAT)
Platelet ? of > 50 % from baselineafter = 5 days of heparin (earlier if heparin given within last 3 months)PLUS
PT and aPTT normal
Lab demonstration of heparin-dependent antibodies- HIT ELISA (PF4) or- HIPA test (heparin induced platelet aggregation test)
7. LMWH and HIT HIT incidence: 2.7 % standard heparin vs. < 1 % LMWH
but: 90-95 % cross-reactivity!
9. Bleeding – MKSAP-Q4 55 yr woman
Planned cholecystectomy
Hx: easy bruising, frequent prolonged nosebleeds
Bleeding after nasal surgery
Blood count normal
PT normal; aPTT 64 sec; aPTT 1:1 mix: complete correction
XII 110 %; XI 16%; IX 98 %; VIII 112 %
10. Factor concentrates PCCs: II, VII, IX, X Bebulin®, FEIBA®, Autoplex®,
Cryo: fibrinogen, von Willebrand factor (factor VIII)
FFP: all other factors (little fibrinogen and von Willebrand factor) half-life of factor VII: 4 h
Humate P: von Willebrand factor, factor VIII
11. Bleeding – MKSAP-Q5 30 yr man
Lifelong epistaxis + easy bruising
Tooth extraction – bleeding for several days
Adopted
Hbg 13.0; MCV 78; plts. 250,000
BT 13.5 min; PT 12 sec; aPTT 40 sec; TCT normal
Platelet aggregation study normal
12. von Willeband’s disease Prevalence: 1 % of population
Bruising – mucosal (nose, gums, menstrual, tonsillectomy, tooth extraction)
13. MKSAP-Q6
14. MKSAP-Q7 27 yr woman
SLE
2 DVTs, now 3rd
PT 13.6 sec; aPTT 43 sec; LA
Standard heparin 5000 U bolus, then 1200 U/h. F/u aPTT 120 sec
15. Antiphospholipid antibodies
16. Lupus anticoagulant 1) Screening test (aPTT, dRVVT, KCT, Silica clot time) – prolonged
2) Normal plasma mixing study – does not correct
3) Confirm (mix with excess of phospholipids) – corrects- hexagonal phospholipid test- platelet neutralization procedure (PNP)
17. MKSAP-Q8 20 yr woman, bleeds after dental extraction
SLE – steroids. No h/o bleeding; plts 160,000;
PT 17.5 sec; corrects with 1:1 mix to 11.4 sec
aPTT 43.3 sec; does not correct with 1:1 mix
Fibrin (ogen) degradation products normal
18. APLA syndrome 1) thrombosis or
2) recurrent abortions
3) pos. APLA test (repeat)
(+ thrombopenia, derm. or neurol. symptoms)
19. MKSAP-Q9 Homocysteine
Factor V Leiden
Prothrombin 20210 mutation
Antiphospholipid antibodies
20. MKSAP-Q10 Factor V Leiden and factor II 20210 gene studies
Protein C, protein S, and antithrombin tests
Screening tests for cancer, incl. Chest and abdo CT
A lupus anticoagulant panel
21. Thrombophilia
22. Factor V Leiden prevalence : 2 - 15 % (western world)
RR for 1st DVT/PE: heterozygotes: 3 - 8 homozygotes: 80 heterozygotes + pill: 30-50
Diagnosis: coagulation test (APC resistance) or genetic test
Not associated with arterial clots (except for selected patients)
23. Prothrombin 20210 polymorphism prevalence: 2.3 % (normal population)
mild risk factor for 1st DVT/PE: RR 2.8
risk for recurrence of DVT/PE: not increased
associated with elevated prothrombin levels
not associated with arterial thrombosis
24. www.fvleiden.org
25. MKSAP-Q11 47 year-old man
DVT after 1 h airplane flight
FH: uncle with DVT after hip arthroplasty, grandfather stroke age 68
Thrombophilia w/u negative
26. DVT/PE: Anticoagulation – how long? after transient risk factors short (6 weeks - 3 mo)
Idiopathic DVT/PE: at least 3 months- Factor V Leiden, hetero at least 3 months- Prothrombin 20210 mutation: at least 3 months- Protein C or protein S deficiency ???
27. MKSAP-Q12 56 yr healthy man
DVT calf and popliteal vein
Adamantly refuses hospitalization
28. MKSAP-Q13 75 yr man
Calf and popliteal DVT after 10 h car ride
Smoking. Otherwise healthy
Phys. exam nl.
CBC, PT, PTT, routine serum chemistry nl
29. MKSAP-Q14 28 yr woman
ACA
three 1st trimester pregnancy losses
Now 6 weeks pregnant
30. MKSAP-Q14 28 yr woman
ACA
three 1st trimester pregnancy losses
Now 6 weeks pregnant
31. MKSAP-Q15 35 yr woman
epistaxis and bruising
Plt: 5,000
Refractory ITP (fails steroids)
32. ITP 1:20,000
Antibodies against platelets, often against GPIIb/IIIa
Dx: negative history, r/o all other causes:
- iron studies (deficiency?)- vitamin B12, folate- blood smear (clumping?)- TSH (hypo?)- HIV(- ANA)- PT, PTT- bone marrow aspirate and biopsy: controversial
33. ITP - Therapy Guided by patient’s bleeding symptoms
Treat when platelets < approx. 20 – 50,000 or when bleeding
Prednisone 1 mg/kg
Slow taper when platelet count > 50,000
34. Questions?