Abstract
TYPE: Late Breaking Case Report TOPIC: Critical Care INTRODUCTION: Thrombosis arising from unusual or multiple locations warrant a thorough search for a cause. The causes are usually underlying pathologies such as cancer, antiphospholipid syndrome, and inherited thrombophilias. CASE PRESENTATION: A 19-year-old patient with obesity presented with a persistent headache. A head CT showed a right transverse sinus thrombosis. Unfractionated heparin was started as first-line treatment, but reaching a therapeutic range of activated partial-thromboplastin time was difficult. Evolution was favorable, and anticoagulation continued with LMWH. Anti-Xa levels were requested and found to be borderline low, requiring modification of therapy. With no other relevant complications, the patient was discharged from ICU. Later, he presented with fever, shortness of breath, dry cough, and pleuritic pain in the right subcostal region. Imaging revealed a pulmonary embolism with thrombosis of the right main and inferior lobar arteries. He persisted with low anti-Xa levels. An antithrombin (AT) study was requested, showing activity of 44% and prompting supplementation. The patient had a favorable clinical evolution and was discharged after 14 days. DISCUSSION: AT deficiency may cause heparin resistance, complicating the thrombotic scenario. Inherited deficiencies are rare, and acquired causes can result from impaired production and reductions from extracorporeal circuits, especially in ECMO support. AT replacement therapy may be used besides anticoagulation in cases of AT deficiency and acute thromboembolism with or without evidence of heparin resistance. CONCLUSIONS: The patient had regular follow-ups, with no new thrombotic episodes and adequate control with vitamin K antagonists. Careful consideration needs to be taken regarding risk factors for heparin resistance in the ICU. DISCLOSURE: Nothing to declare. KEYWORD: heparin resistance
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