Endgames Case Report

A man with acute venous thromboembolism and thrombocytopenia

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1164 (Published 03 February 2014) Cite this as: BMJ 2014;348:g1164
  1. Muhajir Mohamed, consultant haematologist; senior lecturer in medicine12,
  2. Robert Hayes, senior medical scientist3,
  3. Tefo Mosetlhi, trainee medical registrar4
  1. 1Department of Medicine, Launceston General Hospital, Launceston, TAS 7250, Australia
  2. 2University of Tasmania, Launceston Clinical School, Launceston, Australia
  3. 3Department of Pathology, Launceston General Hospital, Launceston, Australia
  4. 4Department of Medicine, Launceston General Hospital, Launceston, Australia
  1. Correspondence to: M Mohamed muhajirbm{at}yahoo.com

A 64 year old man presented to the emergency department with shortness of breath and pleuritic chest pain of 12 hours’ duration. Eight days earlier he had undergone radical prostatectomy for early stage prostatic cancer. He had been given tramadol for analgesia and unfractionated heparin (5000 units subcutaneously) twice a day for four days for postoperative thromboprophylaxis. His full blood counts and biochemical parameters were within normal limits and he was discharged home on the fourth day after surgery with no complications.

His medical history and family history were unremarkable. On examination his respiratory rate was 25 breaths/min, heart rate was 100 beats/min, blood pressure was 130/88 mm Hg, and oxygen saturation in room air was low (90%). Cardiac, respiratory, abdominal, and neurological examinations were normal. His left leg and thigh were swollen but non-tender. There were no bleeding manifestations or evidence of active infection at that time. Chest radiography and electrocardiography were unremarkable.

However, axial computed tomography pulmonary angiography showed extensive thromboemboli in the right and left main pulmonary arteries extending more distally and associated with bilateral wedge shaped pulmonary infarcts (fig 1). Doppler ultrasound showed thrombosis in the left popliteal vein extending up to the common femoral vein. Full blood counts showed low platelets (34×109/L), normal haemoglobin, and normal numbers of white cells. Blood film examination was unremarkable. His coagulation assays, renal parameters, and liver function tests were within normal limits.

Fig 1 Axial computed tomography pulmonary angiogram showing extensive thromboemboli in the right and left main pulmonary arteries (yellow arrows) extending more distally and associated with bilateral wedge shaped pulmonary infarcts (blue arrowheads)

Questions

  • 1 What is the most likely diagnosis in this patient?

  • 2 What are the differential diagnoses?

  • 3. How can this condition be diagnosed?

  • 4 How would you manage this condition?

Answers

1 What is the most likely diagnosis in this patient?

Short answer

Heparin …

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