Spontaneous Heparin-induced Thrombocytopenia Syndrome Presenting As Bilateral Adrenal Infarction After Knee Arthroplasty

Overview

Journal BMJ Case Rep

Specialty General Medicine

Date 2020 Jan 1

PMID 31888903

Citations 5

Authors

Elysha A VanderVeer

Raymond P Torbiak

Ally Ph Prebtani

Theodore E Warkentin

Affiliations

Soon will be listed here.

Abstract

Adrenal gland infarction resulting from adrenal vein thrombosis is an infrequently recognised entity with a limited differential diagnosis. When bilateral, it can result in acute life-threatening adrenal failure. Heparin-induced thrombocytopenia (HIT) is an antibody-mediated, prothrombotic state that represents an important cause of adrenal vein thrombosis leading to associated infarction. Sometimes, the clinical picture of HIT-including the presence of HIT antibodies-occurs despite absence of proximate heparin exposure ('spontaneous HIT syndrome'). We report a case of nearly missed adrenal failure secondary to bilateral adrenal infarction that evolved during the second week following knee arthroplasty (a known trigger of spontaneous HIT syndrome). The combination of bilateral adrenal infarction, thrombocytopenia and presence of platelet-activating HIT antibodies not explainable by preceding heparin exposure led to a diagnosis of postknee arthroplasty spontaneous HIT syndrome. The case also highlights the clinical and laboratory findings associated with rapidly progressive acute adrenal failure.

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References

Greinacher A, Potzsch B, Amiral J, Dummel V, Eichner A, MUELLER-ECKHARDT C . Heparin-associated thrombocytopenia: isolation of the antibody and characterization of a multimolecular PF4-heparin complex as the major antigen. Thromb Haemost. 1994; 71(2):247-51. View

Warkentin T, Kelton J . Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med. 2001; 344(17):1286-92. DOI: 10.1056/NEJM200104263441704. View

Greinacher A . CLINICAL PRACTICE. Heparin-Induced Thrombocytopenia. N Engl J Med. 2015; 373(3):252-61. DOI: 10.1056/NEJMcp1411910. View

Bito S, Miyata S, Migita K, Nakamura M, Shinohara K, Sato T . Mechanical prophylaxis is a heparin-independent risk for anti-platelet factor 4/heparin antibody formation after orthopedic surgery. Blood. 2015; 127(8):1036-43. PMC: 4768427. DOI: 10.1182/blood-2015-06-651620. View

Rosenberger L, Smith P, Sawyer R, Hanks J, Adams R, Hedrick T . Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia. Crit Care Med. 2011; 39(4):833-8. PMC: 3101312. DOI: 10.1097/CCM.0b013e318206d0eb. View

Warkentin T . Heparin-induced thrombocytopenia-associated thrombosis: from arterial to venous to venous limb gangrene. J Thromb Haemost. 2018; 16(11):2128-2132. DOI: 10.1111/jth.14264. View

Greinacher A . Me or not me? The danger of spontaneity. Blood. 2014; 123(23):3536-8. DOI: 10.1182/blood-2014-04-566836. View

Warkentin T, Safyan E, Linkins L . Heparin-induced thrombocytopenia presenting as bilateral adrenal hemorrhages. N Engl J Med. 2015; 372(5):492-4. DOI: 10.1056/NEJMc1414161. View

Chow V, Abnousi F, Huddleston J, Lin L . Heparin-induced thrombocytopenia after total knee arthroplasty, with subsequent adrenal hemorrhage. J Arthroplasty. 2012; 27(7):1413.e15-8. DOI: 10.1016/j.arth.2012.01.012. View

10.

Warkentin T, Makris M, Jay R, Kelton J . A spontaneous prothrombotic disorder resembling heparin-induced thrombocytopenia. Am J Med. 2008; 121(7):632-6. DOI: 10.1016/j.amjmed.2008.03.012. View

11.

Poudel D, Ghimire S, Dhital R, Forman D, Warkentin T . Spontaneous HIT syndrome post-knee replacement surgery with delayed recovery of thrombocytopenia: a case report and literature review. Platelets. 2017; 28(6):614-620. DOI: 10.1080/09537104.2017.1366973. View

12.

Mallik A, Carlson K, DeSancho M . A patient with 'spontaneous' heparin-induced thrombocytopenia and thrombosis after undergoing knee replacement. Blood Coagul Fibrinolysis. 2010; 22(1):73-5. DOI: 10.1097/MBC.0b013e328340ff11. View

13.

Greinacher A, Eichler P, Lietz T, Warkentin T . Replacement of unfractionated heparin by low-molecular-weight heparin for postorthopedic surgery antithrombotic prophylaxis lowers the overall risk of symptomatic thrombosis because of a lower frequency of heparin-induced thrombocytopenia. Blood. 2005; 106(8):2921-2. DOI: 10.1182/blood-2005-05-1824. View

14.

Bakchoul T, Marini I . Drug-associated thrombocytopenia. Hematology Am Soc Hematol Educ Program. 2018; 2018(1):576-583. PMC: 6246020. DOI: 10.1182/asheducation-2018.1.576. View

15.

Warkentin T, Basciano P, Knopman J, Bernstein R . Spontaneous heparin-induced thrombocytopenia syndrome: 2 new cases and a proposal for defining this disorder. Blood. 2014; 123(23):3651-4. DOI: 10.1182/blood-2014-01-549741. View

16.

Jay R, Warkentin T . Fatal heparin-induced thrombocytopenia (HIT) during warfarin thromboprophylaxis following orthopedic surgery: another example of 'spontaneous' HIT?. J Thromb Haemost. 2008; 6(9):1598-600. DOI: 10.1111/j.1538-7836.2008.03040.x. View

17.

Greinacher A, Michels I, Schafer M, Kiefel V, MUELLER-ECKHARDT C . Heparin-associated thrombocytopenia in a patient treated with polysulphated chondroitin sulphate: evidence for immunological crossreactivity between heparin and polysulphated glycosaminoglycan. Br J Haematol. 1992; 81(2):252-4. DOI: 10.1111/j.1365-2141.1992.tb08216.x. View

18.

Pruthi R, Daniels P, Nambudiri G, Warkentin T . Heparin-induced thrombocytopenia (HIT) during postoperative warfarin thromboprophylaxis: a second example of postorthopedic surgery 'spontaneous' HIT. J Thromb Haemost. 2008; 7(3):499-501. DOI: 10.1111/j.1538-7836.2008.03263.x. View

19.

Warkentin T, Levine M, Hirsh J, Horsewood P, Roberts R, Gent M . Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995; 332(20):1330-5. DOI: 10.1056/NEJM199505183322003. View

20.

Elshoury A, Khedr M, Abousayed M, Mehdi S . Spontaneous heparin-induced thrombocytopenia presenting as bilateral adrenal hemorrhages and pulmonary embolism after total knee arthroplasty. Arthroplast Today. 2017; 1(3):69-71. PMC: 4956682. DOI: 10.1016/j.artd.2015.07.003. View