Hematology
Contributions
Type: Publication Only
Background
A 68 years old male patient was addressed for hematological care in the context of polycythemia vera, a recent proximal deep vein thrombosis, and a newly diagnosed rectal tumor requiring resection. The patient had been known for polycythemia vera for 10 years, was treated by hydroxycarbamid and aspirin, and presented stable blood counts. A recently diagnosed left femoro-popliteal thrombosis had been treated by dalteparin. One week after the initiation of anticoagulation he signaled the apparition of extreme, burning pain in the distal region of the thrombosed leg and in the right hand, always starting 1 hour after each injection of dalteparin. The pain persisted for a couple of hours and was not responsive to anti-inflammatory and analgesic treatment. The switch of the low molecular weight heparin (LMWH) to nadroparin did not affect the pain. Clinical examination showed discrete lower limb edema predominantly in the affected side, without sign of ischemia. Imaging did not show an extension of the thrombosis. Discrete thrombocytopenia (137 G/l) was the only anomaly of blood count. Coagulation tests were normal.
Aims
To describe laboratory findings and clinical course of this unsusual case.
Methods
Because of the consistent temporal relation of the pain to the administration of LMWH and the slight degree of thrombocytopenia, anti-PF4/heparin antibodies were assessed. The IgG-monospecific ELISA was highly positive (OD 1.86; cut-off : 0.32). The HIPA test performed in a reference laboratory was negative even if the local ELISA was also highly positive.
Results
Nadroparin was immediately changed to fondaparinux, which allowed prompt and complete resolution of the pain. After one month of fondaparinux treatment a Doppler control of the thrombosis showed thrombus persistence without complete canalization. Blood counts showed discrete anemia and thrombocytosis, and the anti-PF4/heparin antibody level decreased to OD 1.45. The rectal surgery was performed with no complication 36 hours after the last dose of fondaparinux and anticoagulation was resumed in the post-operative phase with argatroban followed by fondaparinux 3 days later. At last follow-up, 1 month after surgery the patient was still on fondaparinux, free of pain and the anti-PF4/antibody level had further decreased (OD 0.98).
Summary
Because of the temporal relation of the patient’s symptoms with the administration of LMWH and the steady decline of anti-PF4/heparin antibodies after switch to fondaparinux, we consider this the first case report of high titer anti-PF4/heparin antibodies uniquely presenting with post-injection pain. We propose that clinicians should be aware that the presence of high titer anti-PF4/heparin antibodies might be related to otherwise unexplained pain after injection of low-molecular weight heparins. In our case, switch to a non-heparin based anticoagulation lead to an immediate disappearance of the post-injection pain.
Keyword(s): Anti-platelet antibody, Pain, Polycythemia vera, Thrombosis
Session topic: Publication Only
Type: Publication Only
Background
A 68 years old male patient was addressed for hematological care in the context of polycythemia vera, a recent proximal deep vein thrombosis, and a newly diagnosed rectal tumor requiring resection. The patient had been known for polycythemia vera for 10 years, was treated by hydroxycarbamid and aspirin, and presented stable blood counts. A recently diagnosed left femoro-popliteal thrombosis had been treated by dalteparin. One week after the initiation of anticoagulation he signaled the apparition of extreme, burning pain in the distal region of the thrombosed leg and in the right hand, always starting 1 hour after each injection of dalteparin. The pain persisted for a couple of hours and was not responsive to anti-inflammatory and analgesic treatment. The switch of the low molecular weight heparin (LMWH) to nadroparin did not affect the pain. Clinical examination showed discrete lower limb edema predominantly in the affected side, without sign of ischemia. Imaging did not show an extension of the thrombosis. Discrete thrombocytopenia (137 G/l) was the only anomaly of blood count. Coagulation tests were normal.
Aims
To describe laboratory findings and clinical course of this unsusual case.
Methods
Because of the consistent temporal relation of the pain to the administration of LMWH and the slight degree of thrombocytopenia, anti-PF4/heparin antibodies were assessed. The IgG-monospecific ELISA was highly positive (OD 1.86; cut-off : 0.32). The HIPA test performed in a reference laboratory was negative even if the local ELISA was also highly positive.
Results
Nadroparin was immediately changed to fondaparinux, which allowed prompt and complete resolution of the pain. After one month of fondaparinux treatment a Doppler control of the thrombosis showed thrombus persistence without complete canalization. Blood counts showed discrete anemia and thrombocytosis, and the anti-PF4/heparin antibody level decreased to OD 1.45. The rectal surgery was performed with no complication 36 hours after the last dose of fondaparinux and anticoagulation was resumed in the post-operative phase with argatroban followed by fondaparinux 3 days later. At last follow-up, 1 month after surgery the patient was still on fondaparinux, free of pain and the anti-PF4/antibody level had further decreased (OD 0.98).
Summary
Because of the temporal relation of the patient’s symptoms with the administration of LMWH and the steady decline of anti-PF4/heparin antibodies after switch to fondaparinux, we consider this the first case report of high titer anti-PF4/heparin antibodies uniquely presenting with post-injection pain. We propose that clinicians should be aware that the presence of high titer anti-PF4/heparin antibodies might be related to otherwise unexplained pain after injection of low-molecular weight heparins. In our case, switch to a non-heparin based anticoagulation lead to an immediate disappearance of the post-injection pain.
Keyword(s): Anti-platelet antibody, Pain, Polycythemia vera, Thrombosis
Session topic: Publication Only