Table 1 Patient baseline characteristics and parameters for inflammation and coagulopathy.
Variable | Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 |
|---|---|---|---|---|---|
Age (yrs) | 51 | 79 | 31 | 36 | 51 |
BMI (kg/m2) | 26 | 33 | 30 | 30.7 | 22.6 |
Sex | Male | Male | Male | Male | Male |
Past Medical History | Diabetes | Prostate Carcinoma (remission) | Thalassemia, Asthma | None | Hypertension |
Admission Thromboprophylaxis Regimen | Heparin SC 5000 TID - Heparin SC 7500 TID on Day 2, based on D Dimer over 3 | Heparin SC 5000 TID | Enoxaparin 40 mg daily | Enoxaparin 40 mg daily, increased to 40 mg BID on day 7 | Heparin 7500 TID |
Signs of thrombosis | Day 3: On observation, ischemia of the first 3 toes, no capillary refill | Day 17: No specific signs, bilateral lower extremity ultrasound ordered based on persistently high D Dimer | Day 7: Bilateral lower limb pain | Day 11: No specific signs but CT angiogram obtained for persistent severe hypoxemia and high D Dimer | Day 13: No specific signs but CT chest with IV contrast obtained to rule out collection |
Imaging Requested | CT Angiogram (abdomen and pelvis with lower extremity runoff): Floating thrombi noted 4 cm infrarenal abdominal aorta compromising the lumen with total obliteration of the right popliteal artery and right anterior tibial artery | Bilateral lower extremity Ultrasound: The right posterior tibial vein appears dilated with visible thrombus | Bilateral lower extremity Ultrasound: Occlusive deep vein thrombosis of the right distal femoral, popliteal, posterior tibial, and peroneal veins, and the left popliteal, gastrocnemius and peroneal veins | CT Angiogram Chest: Large saddle embolus, extension of embolus into the upper and lower lobar pulmonary arteries with right heart strain | CT Chest with IV Contrast: Multiple filling defects noted bilaterally in the pulmonary tree; findings consistent with pulmonary embolism. Small filling defect seen in the internal jugular veins bilaterally, consistent with thrombi. |
Vascular Intervention | 1.Percutaneous mechanical thrombectomy of the infrarenal aorta 2. Left lower extremity intra-arterial thrombolysis | None | None | None | None |
Pharmacologic Antithrombotic Therapy for Confirmed thrombosis | Heparin Drip per DVT/PE protocol (aPTT target 60–85) | Enoxaparin 1 mg/kg BID from day 17 till day 29 of admission when patient developed AKI and switched to heparin drip | Enoxaparin 1 mg/kg BID, switched to heparin drip on day 10 of admission | Systemic alteplase followed by heparin DVT/PE protocol (aPTT target 60–85) | Heparin Drip per DVT/PE protocol (aPTT target 60–85) |
Secondary ischemia of bilateral lower extremity, developing left foot dry gangrene requiring below-knee amputation. Patient improved and discharged on oral anticoagulation. | Expired on day 38 of admission, while on heparin drip therapeutic dose for DVT/PE (aPTT target 60–85), CRRT, and mechanical ventilation. Potential PE | Discharged on oral anticoagulation with apixaban on day 17 of admission | Patient improved and was transferred to a medical ward on day 14 of admission and eventually discharged home on oral anticoagulation on day 21 of admission | Developed bacteremia and cavitary lung disease with confirmed aspergillosis, which progressed to invasive form with hemoptysis. Patient had a cardiac arrest and expired on day 76 of admission while on therapeutic IV heparin and mechanical ventilation. | |
Tocilizumab | Prior to admission at OSH | Day 3 | Day 1 | Day 3 | Day 2 |
D-Dimer (mcg/mL) | |||||
Admission | Over 4 | Over 4 | 2.05 | 0.54 | Over 4 |
At time of event | Over 4 | Over 4 | Over 4 | Over 4 | Over 4 |
Platelets (×10*9/L) | |||||
Admission | 311 | 180 | 311 | 201 | 278 |
At time of event | 218 | 161 | 218 | 474 | 515 |
C-Reactive protein (mg/L) | |||||
Admission | 8 | 193 | 63.2 | 59.3 | 307.5 |
At time of event | 3.8 | 49 | 3.8 | 3.5 | 297.2 |
Fibrinogen (g/L) | |||||
Admission | 1.88 | NA | 6.57 | 4.53 | 7.06 |
At time of event | 1.4 | 5.01 | 3.29 | 2.53 | NA |
Lupus Anticoagulant | Negative | N/A | Positive | Positive | Positive |