Intravascular Coagulation Research Articles

Risk Factors for Mortality in Critically Ill Patients with Coagulation Abnormalities: A Retrospective Cohort Study.

Coagulation abnormalities are common and prognostically significant in intensive care units (ICUs) and are associated with increased mortality. This study aimed to explore the association between the levels of coagulation markers and the risk of mortality among ICU patients with coagulation abnormalities. This retrospective study investigated patients with coagulation abnormalities in the ICU between January 2021 and December 2022. The initial point for detecting hemostatic biomarkers due to clinical assessment of coagulation abnormalities was designated day 0. Patients were followed up for 28 days, and multivariate logistic regression analysis was utilized to identify risk factors for mortality. Of the 451 patients analyzed, 115 died, and 336 were alive at the end of the 28-day period. Multivariate analysis revealed that elevated thrombin-antithrombin complex (TAT), tissue plasminogen activator inhibitor complex (tPAIC), prolonged prothrombin time, and thrombocytopenia were independent risk factors for mortality. For nonovert disseminated intravascular coagulation (DIC) patients, older age and thrombocytopenia were associated with increased risks of mortality, whereas elevated levels of plasmin α2-plasmin inhibitor complex (PIC) were found to be independent predictors of survival. In patients with overt DIC, elevated levels of tPAIC were independently associated with increased risks of mortality. Nevertheless, thrombocytopenia was independently associated with increased risks of mortality in patients with pre-DIC. Coagulation markers such as the TAT, tPAIC, PIC, and platelet count were significantly associated with mortality, underscoring the importance of maintaining a balance between coagulation and fibrinolysis. These findings highlight the potential for targeted therapeutic interventions based on specific coagulation markers to improve patient outcomes.

Pediatric Scapular Cavernous Hemangioma Presenting with Kasabach–Merritt Syndrome and Controlled by Preoperative Angioembolization: A Case Report

AbstractIntraosseous hemangioma is a common and benign vascular tumor with a propensity to occur in any bone of the body. Although the most common skeletal sites are the craniofacial bones and the spine, hemangioma of the scapula is a rare occurrence, which is rarer in the pediatric population. Kasabach–Merritt syndrome (KMS) is characterized by the combination of a rapidly growing vascular tumor, thrombocytopenia, microangiopathic hemolytic anemia, and consumptive coagulopathy. This condition can cause massive bleeding even after minor trauma and immediate operative management is usually contraindicated.We report a rare case of KMS in an 8-year-old girl with cavernous hemangioma of the scapula presenting with progressively increasing shoulder mass, thrombocytopenia, and serially falling hemoglobin levels. She was treated with preoperative angioembolization to manage the consumptive coagulopathy followed by surgery poststabilization. Intraosseous hemangiomas, while benign, can show aggressive features on imaging and angioembolization can be a life-saving tool in the management of vascular tumors presenting with consumptive coagulopathy. Intraosseous hemangiomas, while benign, can show aggressive features on imaging and angioembolization can be a life-saving tool in the management of vascular tumors presenting with consumptive coagulopathy.

A retrospective study on safety and efficacy of recombinant human soluble thrombomodulin to acute aortic dissection with disseminated intravascular coagulation

ObjectivesRecombinant human soluble thrombomodulin (rTM) has recently been used as a promising therapeutic natural anti-coagulant drug for disseminated intravascular coagulation (DIC). Here we investigated the safety and efficacy of rTM after aortic surgery in patients with acute aortic dissection (AAD).MethodsA total of 316 patients diagnosed with AAD underwent emergent ascending aortic replacement or total arch replacement between 2010 and 2019. We retrospectively analyzed the clinical information of 62 patients with the Japanese Association for Acute Medicine’s acute-stage DIC diagnostic criteria (JAAM criteria) with a score of ≥ 4. We assigned 62 patients to two groups, either non-rTM group (n = 29) or rTM group (n = 33). Patient characteristics, surgical procedures, and postoperative outcome data including coagulation function and the JAAM DIC score in both groups were collected.ResultsThe decrease in the number of platelets was clearly suppressed on days 1–3 in the rTM group. On days 1–4, fibrin degradation product levels were upregulated in the non-rTM group but significantly downregulated in the rTM group. Five operative deaths occurred within 30 days postoperative (two [6.9%] in the non-rTM group vs. three [9.1%] in the rTM group). The JAAM DIC score showed a gradually improving trend from postoperative day 1 in the rTM group.ConclusionsPostoperative rTM administration for AAD may be a safe and promising novel treatment strategy for improving the JAAM DIC score.

Adult-Onset Still's Disease (AOSD)-On the Basis of Own Cases.

Adult-onset Still's disease (AOSD) is a rare chronic autoinflammatory condition characterized by a spiking fever, arthritis, a rash, hepatosplenomegaly, lymphadenopathy, leucocytosis, and hyperferritinemia. It is sometimes accompanied by life-threatening complications like macrophage activation syndrome/hemophagocytic lymphohistiocytosis (MAS/HLH). Treatment options for AOSD include glucocorticoids (GCs), immunosuppressive drugs, biological medications, and Janus kinase (JAK) inhibitors. The features that differentiate MAS/HLH from AOSD are: in MAS/HLH, a different type of fever, which is persistent, a sharp decrease in the number of leukocytes and thrombocytes, a further increase in the level of transaminases and ferritin, significant hepatosplenomegaly, lymphadenopathy, symptoms of the central nervous system (CNS), disseminated intravascular coagulation (DIC) and hemophagocytosis in the bone marrow. This study aimed to evaluate the course of AOSD, which results in MAS/HLD. Nine AOSD patients, four of whom developed MAS/HLH, were treated at the Rheumatology Clinic in the Central Clinical Hospital of the Ministry of Interior Affairs from 1 January 2015 to 15 March 2020 and at the Rheumatology Clinic in the National Institute of Geriatric, Rheumatology and Rehabilitation from 1 September 2021 to 1 March 2024. Medical history, clinical data, demographic data, laboratory data, imaging data, Hscore, and treatment data were collected. All the patients with MAS and an Hscore above 150 recovered. MAS/HLH requires rapid diagnosis as well as treatment with methylprednisolone pulses, cyclosporine A, and etoposide. When comparing patients who developed MAS/HLH with those who did not, possible risk factors were identified: the presence of pregnancy (two cases) and an aggressive course of AOSD. The Hscore is a useful tool for identifying patients with MAS/HLH.

Extracorporeal life support for severe leptospirosis: Case series and narrative review

Introduction: Leptospirosis can be associated with multi-system organ failure (MSOF) and significant morbidity and mortality. Extracorporeal life support (ECLS) has been used as salvage therapy for severe leptospirosis complicated by acute respiratory distress syndrome (ARDS). Current knowledge in this field is limited, with no standardized treatment approaches. We aim to describe the literature to date on the use of ECLS in patients with leptospirosis, highlighting associations, outcomes, and complications. Methods: We report on the successful use of ECLS in two cases of severe leptospirosis and conduct a narrative review of the literature. Using a search strategy developed in consultation with a medical librarian and validated across pre-selected articles, several databases were searched. We included case reports, case series, cohort studies, and prospective studies of adult patients with confirmed leptospirosis undergoing ECLS. Editorials, surveys, or opinion articles without primary patient data were excluded. Overall mortality was our primary outcome. Results: Two cases of previously healthy males presenting with ARDS due to leptospiral infection are described. Literature review identified 25 articles containing 43 reported cases of patients treated with ECLS for severe leptospirosis. Patients were mostly young and male. Overall mortality was 16%. The most common complication recognized was acute renal failure requiring renal replacement therapy. Additional complications included diffuse intravascular coagulation, necrotizing pancreatitis, and limb ischemia. Conclusion: Leptospirosis should be considered in patients with epidemiologic exposure(s) presenting with critical illness, including ARDS and MSOF. ECLS is a viable rescue strategy in severe leptospirosis, even with established MSOF.

Expression of antigen-presenting cells in lung of postmortem SARS-CoV-2 cases.

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a deadly pulmonary disease with impaired immunological response that causes significant tissue damage and organ failure. Postmortem examination of the lung is a useful tool for understanding the immunopathogenesis of this virus. Lung autopsy samples from seven dead SARS-CoV-2 patients were obtained and evaluated using hematoxylin and eosin stain to analyze the histopathological changes in those samples, on the other hand, Immunohistochemical (IHC) staining was used for detection of CD21, CD1a, CR1 (CD35), CD68, Myeloperoxidase (MPO), CD15, CD56, CD3, CD20, CD4, and CD8 cells markers. Histopathological examination revealed diffuse alveolar damage with extensive parenchymal architecture distortion, intravascular fibrin clot, deposition of collagen fibers, vascular congestions and blood vessels containing thrombi, pneumocyte type II with inflammatory cell infiltration. The IHC staining for the innate immune cells such as antigen-presenting cells (APCs) including dendritic cells, Macrophages, and neutrophils showed a strong positive staining, while CD56 Natural killer (NK) cells showed negative staining. On the other hand, the specific immune cells including; CD20 B cells, CD3 T cells, and CD4 helper T cells, showed positive staining while CD8 Cytotoxic T cells showed negative staining. The lung autopsy samples from patients with COVID-19 confirmed the presence of APCs through the positive staining of CD21, CD1a, CD35, CD68, MPO, and CD15 expressed the virus recognition, proinflammatory cytokine production, and adaptive immune cells activation through CD3, CD4, and CD20 positive staining and the role of APCs in the severity of pulmonary infection and pathogenesis of SARS-CoV-2 infection however the absence of the CD56 NK and CD8 cytotoxic T explains the worse infection status for the patients.

“Deep Purple”: un caso di purpura fulminans in asplenia congenita isolata

Asplenic patients are well-known to be at higher risk of infections, which are primarily caused by Streptococcus pneumoniae. Such infections may present with a sudden onset and a fulminant course, potentially leading to septic shock, purpura fulminans and other severe complications. The authors present the case of a 2-year-old child with an undiagnosed asplenia, who developed septic shock caused by S. Pneumoniae, and subsequently, a volvulus due to intestinal malrotation. Purpura fulminans is a rare, life-threatening condition characterised by disseminated intravascular coagulation, extensive tissue thrombosis and haemorrhagic skin necrosis. It is primarily associated with meningococcal or pneumococcal infec-tions. Approximately half of pneumococcal purpura fulminans cases occur in asplenic or hyposplenic patients. Pneumococcal vaccination may reduce the risk of infection in asplenic patients, although it does not entirely eradicate this risk. When encountering a septic patient presenting with purpura fulminans, it is crucial to consider the potential underlying asplenia as part of the differential diagnosis.

Evaluation of Coagulation Disorders in Intubated and Non-Intubated Patients with Covid-19 Diagnosis in The Intensive Care unit

Objective: It is known that the need for invasive mechanical ventilation due to severe respiratory failure develops in COVID-19 patients followed in the intensive care unit. It has been reported in the literature that coagulopathy seen during COVID-19 disease is an important cause of mortality and morbidity. Our aim in our study was to evaluate coagulation disorders developing between intubated and non-intubated patients. Method: The data of 812 patients diagnosed with COVID-19 in the Intensive Care Unit, between March 2020 and September 2021 were retrospectively analyzed. The patients were divided into two groups according to the need for invasive mechanical ventilation. Demographic characteristics, laboratory values at the time of diagnosis, coagulopathy development status and survival of the patients were investigated. Results: Of the 812 patients included in the study, 459 (56.5%) were male. The mean age was 66,4 ± 15,2. 257 (31.7%) of the patients received invasive mechanical ventilation support. Coagulopathy was detected in 146 (56.8%) of these patients. Distribution of coagulopathy in intubated patients; 26% Disseminated Intravascular Coagulation, 17.9% Acute Coronary Syndrome, 10.5% Hemorrhage (inside or outside the body), 5.4% Pulmonary Embolism, 5% Heparin-Induced Thrombocytopenia, 3.5% Ischemic Stroke, 1.9% Hemorrhagic Stroke and 0.8% found as Deep Vein Thrombosis. We found that 32% of the patients who were not intubated developed coagulopathy, and this difference was statistically significant (p

Hematological features and alternate diagnoses in critically ill thrombotic antiphospholipid syndrome patients.

Severe thrombotic antiphospholipid syndrome (APS) frequently affects the kidney, heart, and central nervous system. The precise frequency, clinical picture, differential diagnoses, and outcome of APS-related hematological involvement are lacking, especially in patients requiring ICU admission. This study aimed to describe the hematological manifestations associated with critically ill thrombotic APS patients and catastrophic antiphospholipid syndrome. This French, national, multicenter, retrospective study, conducted, from January 2000 to September 2018, included all APS patients admitted to 24 participating centers' ICUs with any new thrombotic manifestation. The prevalence of hematological manifestations and their associated outcomes were studied. One hundred and thirty-four patients, female 72%, median [IQR] age 45 [34-56] years, with 152 episodes were included. Anemia was present in 95% of episodes and thrombocytopenia in 93%. The lowest values for hemoglobin and platelets were 7.1 [6.3-8.8] g/dL and 38 [21-60] g/L, respectively. The lowest platelet count below 20g/L was significantly associated with a higher in-ICU mortality rate (50%, p < 0.0001). A thrombotic microangiopathy syndrome (TMA) syndrome was seen in 16 patients (12%) and was associated with higher in-hospital mortality (p = 0.05). Median ADAMTS-13 levels were 44% [27-74]. Anti-ADAMTS13 antibodies were tested in 11 patients and found negative in all. A suspicion of heparin-induced thrombocytopenia (HIT) was raised in 66 patients but only four patients were classified as definite HIT. Disseminated intravascular coagulation (DIC) was seen in 51% of patients. Thrombocytopenia is very frequent in severe APS patients and may be related to TMA, HIT, or DIC. Deciphering the mechanisms of thrombocytopenia is decisive in CAPS patients. Key Points • Thrombocytopenia is the hallmark laboratory finding in CAPS. • A complete thrombotic microangiopathy pattern is infrequent in CAPS patients. • Alternate diagnoses of CAPS, especially heparin-induced thrombocytopenia, need to be adequately investigated.

Maternal and Fetal Outcomes in Disseminated Intravascular Coagulation Cases Associated with Pregnancy Complications.

The relationship between the pregnancy modified DIC score, which is applied in obstetric conditions where the risk of disseminated intravascular coagulation is high, and underlying disease, as well as its effect on the prognosis, was investigated. Those with a DIC score ≥ 26 from obstetric conditions, such as obstetric bleeding, placental abruption, or preeclampsia/HELLP syndrome, which are at high risk of developing DIC, were included in the study. These patients were compared in terms of laboratory results, maternal morbidity/mortality, and neonatal outcomes, according to the underlying disease. The DIC score was ≥ 26 in 224 of 154,233 deliveries in our center, and the incidence was 0.14%. In the preeclampsia/HELLP syndrome group, the platelet count and prothrombin time were lower, and the fibrinogen level was higher than those of the obstetric hemorrhage and placental abruption groups. In addition, the rates of blood transfusion and hysterectomy were lower in women who developed DIC due to pre-eclampsia/HELLP syndrome than in those with obstetric hemorrhage. Considering the underlying disease is an important factor in predicting prognosis, when using the new pregnancy modified diagnostic scores for DIC diagnosis.

Progress on improving animal welfare and experiment translatability using an animal model of venom induced consumption coagulopathy

Progress on improving animal welfare and experiment translatability using an animal model of venom induced consumption coagulopathy

Clinical and Pathoanatomical Characteristics of Hypoplastic Left Heart Syndrome a Clinical Case

Hypoplastic left heart syndrome (HLHS) is a common congenital heart defect, accounting for 4 to 16% of cases, and is one of the most prognostically unfavorable, involving single-­ventricle hemodynamics. HLHS involves hypoplasia of the left ventricle, often in combination with atresia and/or stenosis of the aortic and/or mitral valves, as well as hypoplasia of various parts of the aorta. Intrauterine reduction in blood flow to the left heart structures at early stages of fetal development subsequently leads to severe changes in cardiac structures, often not amenable to surgical correction. Objective. To study the clinical and morphological features of HLHS using a clinical case as an example. Materials and Methods. The patient was a child from the first pregnancy, which was complicated by anemia and first-­trimester preeclampsia. The defect was diagnosed prenatally at 23/24 weeks. At 39 weeks, labor was induced, and the infant was hospitalized in the intensive care unit with symptoms of cardiac and respiratory failure. On the 6th day of life, surgical treatment was performed — a Norwood operation, which is a single-­ventricle hemodynamic surgical correction of the defect. Despite intensive care measures, multiple organ failure progressed, leading to the development of disseminated intravascular coagulation (DIC) and subsequent death on the 10th day of life. Results. Autopsy, including staining of the myocardium with Masson’s trichrome and hematoxylin and eosin, showed pronounced plethora of the microcirculatory vessels with formation of erythrocyte thrombi. Pronounced perivascular edema and fraying of muscle fibers were detected. Fibroelastosis of the endocardium of the left ventricle was observed, characterized by pronounced sclerotic thickening due to significant proliferation of fibrous tissue, with the spread of connective tissue strands into the myocardium. Endocardial fibroelastosis is a component of HLHS and one of the determining factors in the outcome of cardiac surgery. Conclusion. The results of this work indicate the complexity of HLHS as a developmental defect, the severity of its clinical manifestations, and the limited prospects of currently existing surgical treatment methods. These patients may require heart transplantation in the first days of life. A potential alternative to early postnatal heart transplantation may be the development of methods for intrauterine correction of the existing developmental defect.

Disseminated Intravascular Coagulation Score and Mortality in Adult Sepsis Patients

Amaç: Bu çalışmada, yoğun bakım ünitesindeki (YBÜ) erişkin sepsis hastalarında dissemine intravasküler koagülasyon (DİK) skoru ile mortalite arasındaki ilişkiyi değerlendirmeyi amaçladık. Gereç ve Yöntem: Bu retrospektif kohort çalışmaya iki yüz yirmi dört hasta dahil edilmiştir. Demografik özellikler, klinik veriler ve laboratuvar sonuçları değerlendirilmiştir. Sürekli değişkenler arasındaki ilişki Spearman sıra korelasyon katsayısı ile analiz edildi. DİK gelişimi için risk faktörleri Bakward Wald yöntemi kullanılarak ikili lojistik regresyon analizi ile araştırıldı. Mortaliteyi öngörme açısından sıralı organ yetmezliği değerlendirme (SOFA) skoru ve Uluslararası Tromboz ve Hemostaz Derneği’nin DİK skoru ROC analizi ile değerlendirildi. Eşik değerin belirlenmesinde Youden J indeksi dikkate alndı. p&lt;0.05 istatistiksel olarak anlamlı kabul edildi. Bulgular: Sepsis ilişkili aşikar DİK hastaların %34.8’inde (n=78) gelişti. Bu hastalarda mortalite (%75,6), aşikar DİK gelişmeyen hastalardaki mortaliteden (%41,1) anlamlı derecede yüksekti, p&lt;0,001. Albümin (r=-0.295), nötrofil (-0.282) ve lenfosit sayısı (-0.247) DİK skoru ile negatif korelasyon gösterirken (tümü için p&lt;0.001); SOFA skoru (r=0.413, p&lt;0.001), laktat (r=0.196, p=0.021) ve prokalsitonin (r=0.209, p=0.022) pozitif korelasyon göstermiştir. Hematolojik malignite varlığı, akut böbrek hasarı ve başvuru sırasındaki SOFA skorları aşikar DİK gelişimi için risk faktörleri olarak belirlenmiştir. Mortaliteyi öngörmede; DİK skor için kesim noktası &gt;4 olarak belirlenmiş olup duyarlılık, özgüllük değerleri sırası ile %49,58 ve %83,65 olarak elde edilmiştir (p&lt;0,001). SOFA skor için ise kesim noktası &gt;7 olarak belirlenmiş olup duyarlılık, özgüllük değerleri sırası ile %60,50 ve %62,85 olarak elde edilmiştir (p&lt;0,001). SOFA skor ve DİK skor mortaliteyi öngörme açısından ROC analizi ile birbiri ile karşılaştırıldığında anlamlı fark saptanmamıştır (p=0.07). Sonuç: Sonuç olarak, yüksek SOFA skorunun mortalite ile ilişkisi literatürde kılavuzlarda vurgulanmaktadır. Buna ek olarak, çalışmamız DİK skorunun da mortalite ile ilişkisini SOFA skor ile karşılaştırarak ortaya koymaktadır.

Handheld point-of-care devices for snakebite coagulopathy: a scoping review.

Venom induced consumption coagulopathy (VICC) is a common complication of snakebite that is associated with hypofibrinogenaemia, bleeding, disability, and death. In remote tropical settings, where most snakebites occur, the 20-minute whole blood clotting test is used to diagnose VICC. Point-of-care (POC) coagulation devices could provide an accessible means of detecting VICC that is better standardised, quantifiable, and more accurate. In this scoping review, the mechanistic reasons that previously studied POC devices have failed in VICC are considered, and evidence-based recommendations are made to prioritise certain devices for clinical validation studies. Four small studies have evaluated a POC international normalised ratio (INR) device in patients with Australian Elapid, Daboia russelii and Echis carinatus envenoming. All of these studies used POC INR devices that rely on a thrombin substrate endpoint, which, unlike laboratory-based INR measurement, is known to underestimate INR in patients with hypofibrinogenaemia. Seventeen commercially available POC devices for measuring INR, activated clotting time (ACT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer, and fibrin(ogen) degradation products (FDP) have been reviewed. POC INR devices that detect fibrin clot formation, as well as a novel POC device that quantifies fibrinogen were identified, that show promise for use in patients with VICC. These devices could support more accurate allocation of antivenom, reduce the time to antivenom administration, and provide improved clinical trial outcome measurement instruments. There is an urgent need for these promising POC coagulation devices to be validated in prospective clinical snakebite studies.

Effect of platelet dynamic changes on disseminated intravascular coagulation and prognosis in severe heatstroke patients

ABSTRACT Objective This study aimed to investigate the dynamic changes in the platelets of patients with severe heatstroke and the impact of these changes on the occurrence of disseminated intravascular coagulation (DIC) and prognosis in them. Methods This retrospective cohort study conducted at two tertiary hospitals recruited 264 patients with severe heatstroke. Logistic regression was used to analyze the association between platelet counts and DIC. The receiver operating characteristic (ROC) curve was used to evaluate the predictive performance of platelets count for DIC occurrence. We used mediation effect to analysis the role of DIC as a mediating variable to mediate the relationship between platelet count decrease after 24 hours and death. Results There were 214 patients with lower platelet counts compared to admission (107 × 109/L[69,168] vs.171 × 109/L[126,215], p < 0.001). The DIC patients had lower platelet counts than the non-DIC patients when measured in the emergency department and after 24 hours. The platelet count decrease after 24 hours was a risk factor for DIC (odds ratio [OR] = 2.710, 95% confidence interval [CI] = 1.069–6.869). The results of the ROC curve revealed that the predictive performance of the platelet count after 24 hours (area under the curve [AUC] = 0.8685, 95% CI = 0.8173–0.9197) was significantly better than that of the platelet count measured in the emergency department (AUC = 0.7080, 95% CI = 0.6345–0.7815). Mediation analyses showed that PLT decrease after 24 hours did not directly lead to death, but can indirectly cause death by inducing the development of DIC. Conclusions Decreased platelet count is an independent risk factor for DIC in patients with severe heatstroke. Although the platelet counts measured in the emergency department and after 24 hours show a good predictive performance for DIC occurrence, the prediction performance of the latter is better.

Palliative Care for Patients With Breast Cancer in a Palliative Care Unit of a Japanese Hospital.

Background This study describes the end-of-life care management in palliative care units (PCUs) for patients with breast cancer in Japan. Methods The medical data of patients admitted to the palliative care unit of Kashiwara Municipal Hospital between October 2017 and December 2023 were analyzed. A chi-square test was conducted to analyze the data using the Excel software (Microsoft Corp., Redmond, WA). Results The most common clinical condition among the 32 patients with breast cancer in our palliative care unit was pleural effusion (17/32, 53.1%), followed by obstructive jaundice (6/32, 18.8%), disseminated intravascular coagulation (DIC) (4/32, 12.5%), and hypercalcemia (1/32, 3.1%). Most patients had no indications for pleural effusion removal, biliary drainage, or anticoagulation therapy. Palliative sedation was performed in 25% of the patients with breast cancer, mainly to relieve intolerable general fatigue. There were no statistically significant differences in the sedation ratios between breast cancer and cancers at other primary sites. Conclusion Palliative treatments using appropriate infusion, narcotics, oxygen administration, various drugs, and sedation were administered in our palliative care unit to relieve symptoms instead of radical treatments for severe clinical conditions of breast cancer.

Thyroid storm with acute liver failure and disseminated intravascular coagulation- lessons in diagnosis and treatment

Thyroid storm is a medical emergency with a high mortality rate. Acute liver failure (ALF) and disseminated intravascular coagulation (DIC) are rarely reported with thyroid storm, and their occurrence is unrelated to the degree of free circulating thyroxine.We present the case of a 41-year-old Sri Lankan female, with a fatal case of thyroid storm. She initially presented with palpitations and heat intolerance, and subsequently developed acute liver failure with hepatic encephalopathy and coagulopathy. There was hypoglycemia and resistant lactic acidosis consequent to the liver failure. The clinical course progressed to DIC and she eventually succumbed to the illness. Treatment comprised the standard management of thyroid storm.This case report highlights the importance of bearing ALF and DIC in mind as complications of thyroid storm, outlines their pathophysiology, and uses pathophysiological mechanisms to justify, evolving extracorporeal therapeutic strategies for resistant cases.

Coagulation dysfunction events associated with echinocandins: a real-world study from FDA adverse event reporting system (FAERS) database

BackgroundEchinocandins belong to the fourth generation of antifungals, and there are no systematic studies on their risk in coagulation dysfunction; this study will predict the risk of coagulation dysfunction of echinocandins using the US Food and Drug Administration Adverse Event Reporting System (FAERS) database.MethodData from January 2004 to March 2024 were obtained from FAERS. We examined the clinical characteristics of the coagulation dysfunction events and conducted disproportionality analysis by using reporting odds ratios (ROR) to compare echinocandins with the full database.ResultsThere were 313 reports of coagulation dysfunction related to echinocandins as the primary suspect (PS) drug. The median time to incident for coagulation dysfunction was 3 (interquartile range [IQR] 1–9) days. Compared to triazoles and polyenes, echinocandins have a stronger signal (ROR 3.18, 95%CI 2.81–3.51, p < 0.01) of coagulation dysfunction. Compared to caspofungin and micafungin, anidulafungin has a stronger signal (ROR 6.84, 95%CI 4.83–9.70, p < 0.01). The strongest signal corresponding to disseminated intravascular coagulation (DIC), platelet count decreased, thrombocytopenia, gastrointestinal haemorrhage, cerebral haemorrhage, pulmonary haemorrhage and thrombotic thrombocytopenic purpura (TTP) is micafungin (ROR 27.19, 95%CI 18.49–39.98), micafungin (ROR 3.50, 95%CI 2.36–5.19), anidulafungin (ROR 9.75, 95%CI 5.22–18.19), micafungin (ROR 3.17, 95%CI 2.02–4.97), micafungin (ROR 4.95, 95%CI 2.81–8.72), caspofungin (ROR 20.76, 95%CI 11.77–36.59), micafungin (ROR 20.43, 95%CI 8.49–49.14), respectively.ConclusionsFor coagulation dysfunction, we found stronger signals for echinocandins than triazoles and polyenes, and stronger signals for anidulafungin than micafungin and caspofungin. Coagulation parameters should be closely monitored while using the respective drugs.

Use of preoperative erythropoietin-stimulating agents is associated with decreased thrombotic adverse events compared to red blood cell transfusion in surgical patients with anaemia.

Preoperative red blood cell (RBC) transfusions increase post-operative venous thromboembolic (VTE) events. Erythropoietin-stimulating agents (ESAs) increase VTE risk in cancer patients; we aimed to assess ESA versus RBC-associated VTE risks in a broad population of surgical patients. We queried TriNetX Diamond Network from 2006 to 2023, comparing patients with anaemia within 3 months preoperatively who received preoperative ESAs with or without intravenous (IV) iron to patients who received preoperative RBCs. Sub-analyses included (1) all surgeries and (2) cardiovascular surgeries. We propensity score matched for demographics, comorbidities, medical services, post-treatment haemoglobin (g/dL) and, for all-surgery comparisons, surgery type. Outcomes included 30-day post-operative mortality, VTE, pulmonary embolism (PE), disseminated intravascular coagulation (DIC) and haemoglobin. In our 19,548-patient cohorts, compared with preoperative RBC transfusion, ESAs without IV iron were associated with lower mortality (relative risk [RR] = 0.51 [95% confidence interval (CI), 0.45-0.59]), VTE (RR = 0.57 [0.50-0.65]) and PE (RR = 0.67 [0.54-0.84]). Post-operative haemoglobin was higher in the ESA without IV iron cohort compared with the transfusion cohort (10.0 ± 1.4 vs. 9.4 ± 1.8 g/dL, p = 0.002). Cardiac surgical patients receiving ESAs with or without IV iron had lower risk for post-operative mortality, VTE and PE (p < 0.001) than those receiving RBCs. Post-operative haemoglobin differed between patients receiving ESAs with IV iron versus RBCs (10.1 ± 1.5 vs. 9.4 ± 1.9 g/dL, p = 0.0009). Compared with surgical patients who were transfused RBCs, ESA recipients had reduced 30-day post-operative risk of mortality, VTE, PE and DIC and increased haemoglobin levels. IV iron given with ESAs improved mortality.

The Phenomenon of Thrombotic Microangiopathy in Cancer Patients.

Thrombotic microangiopathy (TMA) encompasses a range of disorders characterized by blood clotting in small blood vessels, leading to organ damage. It can manifest as various syndromes, including thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), and others, each with distinct causes and pathophysiology. Thrombo-inflammation plays a significant role in TMA pathogenesis: inflammatory mediators induce endothelial injury and activation of platelet and coagulation cascade, contributing to microvascular thrombosis. Primary TMA, such as TTP, is primarily caused by deficient ADAMTS13 metalloproteinase activity, either due to antibody-mediated inhibition or intrinsic enzyme synthesis defects. In cancer patients, a significant reduction in ADAMTS13 levels and a corresponding increase in VWF levels is observed. Chemotherapy further decreased ADAMTS13 levels and increased VWF levels, leading to an elevated VWF/ADAMTS13 ratio and increased thrombotic risk. Drug-induced TMA (DITMA) can result from immune-mediated or non-immune-mediated mechanisms. Severe cases of COVID-19 may lead to a convergence of syndromes, including disseminated intravascular coagulation (DIC), systemic inflammatory response syndrome (SIRS), and TMA. Treatment of TMA involves identifying the underlying cause, implementing therapies to inhibit complement activation, and providing supportive care to manage complications. Plasmapheresis may be beneficial in conditions like TTP. Prompt diagnosis and treatment are crucial to prevent serious complications and improve outcomes.