A patient with pulmonary embolism takes a surprising HIT: a case report
Abstract Background Venous thromboembolism (VTE) is a common condition that may manifest as intermediate or high-risk pulmonary embolism (PE), requiring either primary or subsequent fibrinolytic therapy. In these cases, catheter-directed thrombolysis (CTD) has been shown to be beneficial. Case Summary We present the case of a borderline obese but otherwise healthy 43-year-old male individual, who was admitted with acute intermediate-high risk PE requiring treatment with intravenous unfractionated heparin. After initial therapy failure, the patient received CDT, with subsequent clinical worsening, and a mixed result of imaging studies suggesting partial central worsening and partial peripheral improvement of the thrombotic burden and right ventricular function. A after a multidisciplinary pulmonary embolism response team (PERT) consultation, the diagnosis of heparin-induced thrombocytopenia with normal platelet levels was made. Therapy was changed to intravenous Bivalirudin, with an excellent clinical response and complete recovery of right-ventricular function. The patient was discharged with oral Apixaban therapy, and on follow-up was otherwise well. Discussion Apparent failure of thrombolytic therapy for VTE warrants a clinical investigation into possible causes of a pro-thrombotic state. In this case, the diagnosis of HIT was surprising, especially due only a mild decline in platelet levels, that were well within normal range. We also acknowledge the significance of our PERT in the key diagnosis made in this case.