Vitamin K-Dependent Coagulopathy in Pediatric Osteomyelitis: A Case Report.

Abstract

Thromboembolism in children is rare and is generally limited to those with genetic disorders of coagulation and diseases that induce a hypercoagulable state1. The incidence of deep vein thrombosis (DVT) in children with osteomyelitis is reported to be much higher (between 5% and 10%) 2-4. In addition to DVT, there are other coagulation abnormalities that occur with osteomyelitis that are often paradoxically “mixed” and include features of hypercoagulability (such as pulmonary embolus and cerebral infarct5) and hypocoagulability with increased risk of bleeding4,6-11. The pathophysiology behind the coagulopathy associated with osteomyelitis is unknown. Because mixed coagulopathies often result from a loss of both procoagulant and anticoagulant factors, we hypothesize that osteomyelitis induces persistent activation of the coagulation system, resulting in consumption of coagulation factors. We present a case of osteomyelitis in a fifteen-year-old boy who developed both hypercoagulable disease (DVT) and hypocoagulable disease (gastrointestinal bleed). Laboratory evaluation revealed a severe consumption of vitamin K-dependent coagulation factors, which responded rapidly to the administration of subcutaneous vitamin K. The patient and his parents were informed that data concerning the case would be submitted for publication, and they provided consent. A fifteen-year-old previously healthy boy presented with a three-day history of left knee pain after minor trauma, fever, and inability to bear weight. A summary of the laboratory findings throughout hospitalization is presented in Figure 1. Magnetic resonance imaging (MRI) of the left leg revealed a large subperiosteal abscess and osteomyelitis of the distal part of the femur (Fig. 2-A). The patient subsequently underwent irrigation and debridement. Intraoperative duplex ultrasound showed an occlusive thrombus in the left superficial femoral and popliteal veins (Figs. 2-C, 2-D, and 2-E). Methicillin-sensitive Staphylococcus aureus grew on both blood and intraoperative cultures. Fig. 1 Coagulation and inflammatory changes …