TO CLOT OR NOT TO CLOT

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Autoimmune disorders predispose to venous thromboembolism (VTE), which can be difficult to manage. We present a unique case of difficult to control acute on chronic VTEs in a patient with multiple, overlapping, autoimmune disorders. CASE PRESENTATION: A 48-year-old nulligravida African-American female with a history of recurrent VTEs requiring inferior vena cava filter presented with sudden onset shortness of breath. On presentation, the patient was tachycardic but otherwise stable. Physical exam revealed an obese female in distress with an exquisitely tender left calf. Heparin drip was started for presumed new VTE. EKG showed sinus tachycardia without S1Q3T3 or ST segment or T wave abnormalities. CT PE confirmed bilateral segmental mismatched defects concerning for pulmonary emboli in the bilateral lung bases. Echocardiogram revealed flattening of the interventricular septum consistent with right ventricular strain. Lower extremity ultrasound revealed occlusive DVTs in both common femoral veins. The patient was admitted to the intensive care unit for possible thrombolysis vs thrombectomy, however, she had an acute 3 point drop in Hb (to 6.1) secondary to severe menorrhagia. She was deemed ineligible due to her refusal of blood transfusions and was started on medroxyprogesterone. Given a history of acute on chronic VTEs, autoimmune work up was pursued, which revealed positive lupus anticoagulant and ANA, elevated SSA, anti-Smith, and anti-RNP, and decreased antithrombin-III. Given her highly prothrombotic status, chronic anticoagulation therapy was discussed. The patient specifically requested an easily manageable non-Warfarin regimen. She was started on rivaroxaban and discharged to home with close follow up. The patient re-presented 9 days later with similar symptoms. Her Hb was 3.5. She was transfused 6 units of pRBCs with her consent. An intrauterine device was emergently placed with plans for future hysterectomy. Heparin drip was started post-procedure, however, the patient developed worsening tachycardia and left calf pain. Repeat ultrasound revealed propagation of her known DVT to the left greater saphenous vein. However, vascular surgery noted that the patient would need definitive treatment of uterine bleeding prior to any intervention. Per hematology, the patient was bridged to warfarin given her underlying coagulopathy. The patient’s clinical status remained stable for the next few days, and she was discharged to home on warfarin, medroxyprogesterone, and follow ups within one week. DISCUSSION: Autoimmune diseases are more common in females of reproductive age and can predispose to recurrent VTEs. Anticoagulation with warfarin is preferred, especially in patients with antiphospholipid syndrome. CONCLUSIONS: Patient comorbidities, and preferences, must be taken into account for proper management of the potentially deadly pulmonary manifestations of systemic autoimmune disorders. Reference #1: Cohen H, Hunt BJ, Efthymiou M et al. Rivaroxaban versus warfarin to treat patients with thrombotic antiphospholipid syndrome, with or without systemic lupus erythematosus (RAPS): a randomised, controlled, open-label, phase 2/3, non-inferiority trial. Lancet Haematol. 2016 Sep;3(9):e426-36. https://doi.org/10.1016/S2352-3026(16)30079-5. DISCLOSURES: No relevant relationships by Temidayo Abe, source=Web Response No relevant relationships by Iheoma Alinnor, source=Web Response No relevant relationships by Eric Chang, source=Web Response No relevant relationships by Anyanwoke Chisom, source=Admin input No relevant relationships by Melvin Crawford, source=Web Response No relevant relationships by Chima Odinkemere, source=Web Response No relevant relationships by Parris Tanksley, source=Web Response No relevant relationships by Benjamin Wibonele, source=Web Response