A 67-year-old patient with a history of hypertension, transient ischemic attack, osteoporosis, deep venous thrombosis of the left lower limb with oral anticoagulation with vitamin K, and atrial fibrillation.
She was admitted to the Internal Medicine Department due to acute abdominal pain of three days duration, with normal depositional rhythm and no fever.
The patient is being treated with alendronate, atenol, torasemide, olmesartan, bisoprolol.
The patient presented normal physical examination, except arrhythmic cardiac sounds and epigastric abdominal pain upon palpation.
Abdominal ultrasound showed venous thrombosis and portal vein thrombosis.
An abdominal CT scan confirmed portal vein thrombosis, splenosis and superior mesenteric vein thrombosis.
INR is reviewed where the correct levels of anticoagulation (INR 2-3) are observed from the beginning to the present moment.
Laboratory tests showed moderate thrombocytosis with 400,000 platelets, 12,000 leukocytes, and normal hemoglobin levels.
Biochemistry was performed with proteinogram and immunofixation in serum and urine, and a thrombophilic study determining a lupus anticoagulant, anticardiolipin and beta 2 glycoprotein I, mutation Factor V Leiden, prothrombin 20, was positive.
The diagnosis of portal axis thrombosis probably related to positive JAK2 myelooproliferative syndrome was confirmed.
Treatment with heparin was initiated without regard to the possible need for surgical intervention due to ischemia month that was replaced on the 4 day by enoxaparin at a dose of 1 mg / kg /12 h.
On the seventh day after initiation of heparin therapy, pleural effusion starts on the third day with LMWH decrease in previous platelet levels from one million to 500,000, with a progressive decrease to 123,000/ml on day 12, bilateral effusion.
Chest CT angiography confirmed bilateral pulmonary thromboembolism.
With suspicion of TIH, the technique (ID-PaGIA Heparine/PF4/heparin antibody test/ID-Car) was performed with a positive result and in combination with a high probability, a score of 7-80,000.
