Interesting Case

[SBriggs]

I am in need of some help to determine the cause of a patient's sudden decreased plt. count.

A patient presented to ER shortly after midnight with an elevated INR, relatively normal chemistries, and a normal CBC (WBC 9.9, RBC 4.0, Hgb 13.0, Plt 182). 2 units of plasma were given to the patient between 2am and 6am. When the patient's labs were rechecked at 11:00am, the platelet count had droped to 5 (rest of hemogram looked similar to original). Since this time (it has not been about 36 hours) the patients plt count has remained around 5, WBC count has dropped down to 6.6 and Hgb 11.

The patient had no typical adverse reactions from the plasma transfusion, however the pathologist ordered a culture on the plasma and a transfusion reaction work-up.

Does anyone have any advice on what this may be caused by?

[John C. Staley]

Why was the patient in the ER?? A diagnosis might help us.

:fingerscr

[Malcolm Needs ☆]

Why was the patient in the ER?? A diagnosis might help us.

:fingerscr

Very true John.

I was just wondering whether the plasma contained a strongish HLA or platelet specific antibody, or possibly post-transfusion purpura?

:confused::confused:

[SBriggs]

The diagnosis on the patient is elevated INR that was originally found at another facility and they were then sent to the ER.

We have our blood supplier involved too, they will be reviewing the case and hopefully help determine if the plasma was a causitive factor in this or if it is the patient.

[Deny Morlino]

Has anyone looked at a peripheral smear of the CBC specimen from ER to see if the platelet count of 182 is valid? Might have been an analyzer fluke when the 182 was reported. Love analyzers and would have no reason to doubt them, but when doing a hindsight investigation like this rule out the simple, stupid things first.

[Malcolm Needs ☆]

Has anyone looked at a peripheral smear of the CBC specimen from ER to see if the platelet count of 182 is valid? Might have been an analyzer fluke when the 182 was reported. Love analyzers and would have no reason to doubt them, but when doing a hindsight investigation like this rule out the simple, stupid things first.

That is also a very good point Deny.

I just wonder how quickly the platelet count was done from ER (as to whether it was done immediately - and I mean really quickly) and the others were done after a short time after the draw, and this is a patient whose platelets clump in EDTA? Maybe the platelet count is actually higher on the smear/bloos film, and maybe the count would be higher if the blood were taken into sodium citrate.

Good Lord - I'm almost thinking haematologically. I'll go and lie down for a while.

:confused::confused:

[L106]

While you are lying down, a cold washcloth on the forehead might help, Malcolm.

[Malcolm Needs ☆]

That is also a very good point Deny.

I just wonder how quickly the platelet count was done from ER (as to whether it was done immediately - and I mean really quickly) and the others were done after a short time after the draw, and this is a patient whose platelets clump in EDTA? Maybe the platelet count is actually higher on the smear/bloos film, and maybe the count would be higher if the blood were taken into sodium citrate.

Good Lord - I'm almost thinking haematologically. I'll go and lie down for a while.

:confused::confused:

See what thinking haematologically does to me?

My spelling has never been great, but BLOOS??????????!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:eek::eek:

[jcdayaz]

[b

See what thinking haematologically does to me?

My spelling has never been great, but BLOOS??????????!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:eek::eek:

I was going to ask you what a BLOOS film is.!!!!!:D:D:D;)

I've posted a couple of misspellings myself Malcolm. It is always horrifying to me to go back to one my posts and find a misspelling. I guess it proves that we are all human. Although, I will admit it is refreshing to see that even you are!!:D:D:D:D:D:D

[jcdayaz]

I had a new one the other day. Irriatable blood--it was pronounced EERIA TABLE blood. Sometimes not laughing right in the ear of the nurse calling is quite challenging!! I'm glad I wasn't having dinner at that EEERIA TABLE!!!

[Malcolm Needs ☆]

[b

I was going to ask you what a BLOOS film is.!!!!!:D:D:D;)

I've posted a couple of misspellings myself Malcolm. It is always horrifying to me to go back to one my posts and find a misspelling. I guess it proves that we are all human. Although, I will admit it is refreshing to see that even you are!!:D:D:D:D:D:D

My spelling has always been, shall we say, idiosyncratic (and I had to look that one up in the dictionary too!!!!!!!!!!

:redface::redface:

[John C. Staley]

Back to the case at hand. How elevated was the INR? Was the patient symptomatic, ie, bruising, bleeding etc.? I have a problem understanding why some one would go to the ER in the middle of the night for an elevated INR. You don't just do an IRN without some reason. Could the patient have liver problems and the liver be sequestering (sp check this for me Malcolm) the platelets?

[Malcolm Needs ☆]

Back to the case at hand. How elevated was the INR? Was the patient symptomatic, ie, bruising, bleeding etc.? I have a problem understanding why some one would go to the ER in the middle of the night for an elevated INR. You don't just do an IRN without some reason. Could the patient have liver problems and the liver be sequestering (sp check this for me Malcolm) the platelets?

Hi John,

This isn't my area, but I've just asked one of the experts in the area here, and the answer is yes, liver problem s can cause this, but they are more likely to actually be sequestered in the spleen than the liver.

:):)

[rravkin@aol.com]

Was the INR corrected after the FFP was transfused?

[jcdayaz]

Hi John,

This isn't my area, but I've just asked one of the experts in the area here, and the answer is yes, liver problem s can cause this, but they are more likely to actually be sequestered in the spleen than the liver.

:):)

Yes, in most cases the spleen is the organ sequestering the platelets. In my experience in this area, which is admittedly minimal, that is why they sometimes remove the spleen in platelet disorder situations.

[BrianD]

we sometimes get patients who show an "EDTA-dependant anti-platelet" activity and we have to take the platelet count from a citrated specimen. on the peripheral smear from the EDTA treated whole blood, the few platelets that are found tend to be agranular and "shaped funny."

[AMcCord]

Did the patient get a big bolus of heparin by chance? though the timing seems pretty short for the platelets to disappear if that's the cause of the thrombocytopenia.

[MARINA]

Another option (if the platelet count has been verified by smear and citrate tube) is a Heparin Induced Thrombocytopenia. Is the patient a post operative from somewhere? Have they been exposed to heparin? This is a quick serological test many hospitals do. Sometimes this antibody shows up in four days, but it could take up to a couple of months!