High Risk of Venous Thrombosis Recurrence in Fully Anticoagulated Patient with Antithrombin Deficiency during COVID-19: A Case Report

Coagulation dysfunction is a serious issue in patients with Coronavirus disease-19 (COVID-19). With regard to recently published studies, a high number of patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 developed life-threatening thrombotic complications despite anticoagulation. We report a case of young woman with the type-II heparin-binding site (HBS) antithrombin (AT) deficiency (Budapest 3-homozygous), who developed acute deep vein thrombosis on two occasions due to COVID-19 infection in the course of stable anticoagulation with vitamin K antagonist. The first thrombotic event was observed during mild COVID-19 infection, while the second thrombotic event she developed 2 months after she was negative for severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2). Our case highlights the complexity of the treatment in this particular type of thrombophilia and the need for precaution even in mild forms of viral infection. In the treatment of acute thrombosis, AT-deficient patients may benefit from the use of AT concentrate along with low-molecular weight heparin (LMWH), while in cases of type II-HBS, AT supplementation is mandatory.

Elderly Anticoagulated Patient in General Dental Practice Case Reports from everyday Life

The anticoagulated elderly patient represents a major and sometimes dreaded challenge for the dentist on a daily basis, as postoperative bleeding can lead to serious problems, especially during dental surgical procedures. Knowledge of the various anticoagulants with regard to type, mode of action and influences on dental surgical procedures is indispensable for the dentist. Using case studies from the everyday life of a dental practice in a small town in Thuringia, this problem will be examined in more detail.

Spontaneous thoracolumbar epidural hematoma in an apixaban anticoagulated patient

Background: Spontaneous spinal epidural hematomas (SSEHs) are often attributed to anticoagulation. Although they are rare, they may contribute to significant morbidity and mortality. Case Description: An 83-year-old female with a history of atrial fibrillation on apixaban, presented with 4 days of back pain, progressive lower extremity weakness and urinary retention. When the patient’s MRI showed a dorsal thoracolumbar SSEH, the patient underwent a T10–L3 laminectomy for hematoma evacuation. Within 2 postoperative months, her neurological deficits fully resolved. Conclusion: Apixaban is associated with SSEH resulting in severe neurological morbidity and even mortality. Prompt MRI imaging followed by emergency surgical decompressive surgery may result in full resolution of neurological deficits.

Reliability of the Dilute Russel Viper Venom Time (dRVVT) in Determining Lupus Anticoagulant (LAC) in Anticoagulated Patients

Objectives Antiphospholipid syndrome (APS) can be complicated by thrombosis in the presence of laboratory evidence of persistent antiphospholipid antibodies, usually in the form of a LAC. The diagnostic criteria for APS/LAC require persistent prolongation of two phospholipid-dependent clotting assays, most often the dRVVT and a thromboplastin-based phospholipid-neutralization (PN) assay. When there is discrepancy between tests, LAC diagnosis is inconclusive. This testing is complicated by anticoagulation, which may yield false positive results. We investigated the impact of various anticoagulants on LAC diagnosis by evaluating the rates of dRVVT and PN discrepancy between anticoagulated and non-anticoagulated patients. Methods dRVVT and PN (LAC panel) values were examined for 1452 consecutive patients samples since April 2017, along with anticoagulant status at the time of testing. Each LAC panel was classified as positive (both dRVVT and PN abnormal), negative (both dRVVT and PN normal), or discrepant (one normal and one abnormal). The proportion of discrepant results between anticoagulated and non-anticoagulated patients was calculated and also stratified according to the class of anticoagulant. Results Discrepant results occurred in 161 of 493 anticoagulated patient samples (33%) versus 135 of 1012 non-anticoagulated patient samples (13%). The odds ratio (OR) for a discrepant result for anticoagulated patient samples was 3.15 (95% CI=2.43–4.09) compared to non-anticoagulated patient samples. When narrowed to individual anticoagulant classes, Lovenox had the lowest chance of yielding discrepant results (OR = 1.16 95% CI= 0.51–2.66), whereas Rivaroxaban (OR = 6.9 95% CI= 4.49–10.55) and Warfarin (OR = 5.4 95% CI= 3.43–8.55) had the highest odds of yielding discrepant results. Conclusions Patient anticoagulant status is an important determinant in laboratory testing for APS/LAC. The dRVVT and PN test are 3-fold more likely to yield inconclusive results when a patient is anticoagulated; the type of anticoagulant is even more critical given the large difference in rates of discrepant results for patients on Rivaroxaban and Warfarin versus patients on Lovenox. The difference in discrepancy rate is likely due to the differential impact of each class of anticoagulant on the various components of the coagulation cascade. Rivaroxaban is a direct factor X inhibitor, and Warfarin directly lowers active factor X, amongst other, levels; by contrast, Lovenox, which was not significantly discrepant, requires antithrombin to amplify inhibition of factor II and X activity.

Emergency fasciotomy in an anticoagulated patient with low energy posterior thigh injury

We present a case of a 58-year-old patient with a low energy trauma developing compartment syndrome. He required multiple surgeries, including fasciotomy and removal of a large haematoma. He continued to bleed with a vacuum-assisted closure dressing in situ, requiring prothrombin complex Concentrate and blood transfusion. This case highlights the need for an increased awareness of possible development of compartment syndrome following low impact trauma in a patient who is anticoagulated and raises the question of a possible period of observation for those who may be at risk.