U Aye Myint, male age 76, was admitted to Sakura Hospital on 2.10.2017 with a 20 day complaint of ecchymosis over trunk and extremities.
History of present illness:
Two week duration of Ecchymosis over trunk, extremities, buttock, with painful left buttock swelling. No fever, confusion, joint pain, abdominal pain, bleeding manifestation like epistaxis, hemoptysis, haemetesis, melena or hematuria.
Past Medical History:
Pulmonary TB and treatment 30 years ago. He also has vitiligo which has persisted till now.
Extremities – No joint swelling, ecchymosis present over trunk, nape of neck, buttock and both planter surface of sole.
Eyes – Xanthelesma present, no pallor, no jaundice.
Nose – no epistaxis. Mouth – no active gum bleeding.
Neck – no palpable gland
Leftforearm
Left buttock
CVS examination :
Respiratory examination : Normal
Abdomen examination: Normal
Neurological examination: Normal
Hematology Table 1a
Hematology Table 1B
Urine Analysis and Radiology Table 2
(1) Comment
As Fibrinogen- Degradation Products (FDP) was raised, we excluded DVT with Doppler ultrasound on 10.10.2017.
Diagnosis: Disseminated Intravascular Coagulation (D.I.C.).
Reason for diagnosis;
(a) Presence of skin bleeding
(b) ‘! FDP
(c) ‘! Activated Partial Thromboplastin Time (APTT)
The increased platelet count does not fit with DIC.
First Treatment
DIC treatment included :
- Injection s/c Clexane 60mg (0.6cc) OD for 6 days
- P/O Warfarin 3mg OD
- P/O Lasix 40mg OD
- P/O Alkay 2bd OD
- IV Augmentin 1.2 G (ATD) 12hr for 6 days
- P/O Gemfibrisol 600mg (1) bd as Triglyceride level was elevated
Patient was discharged from hospital on request (11.10.17) and readmitted to hospital on 20.10.17 with the complaint of :
- Diffuse spontaneous bleeding under tongue
- Cheek hematoma
Diagnosis was persistence of DIC and infection – injection abscess.
Hematology Table 2
- 3. Haematuria
- 4. Dyspnea on minimal exertion
Diagnosis
Comment
Causes of DIC
Infection
E. Coli, Streptococci, Neisseria meningitis, Malaria
Cancer
- Pancreas
- Pumonary
- Prostate
Obstetric
- Placental abruption
- Retained dead fetus
- Pre-eclampsia
- Amniotic fluid embolism
- Fibrinogen is reduced in DIC but in this case, fibrinogen can be elevated in infection as it is an acute reactant.
Treatment : antibiotics Baquire 1gm OD and Clexane - Platelet count is reduced in DIC but this pa- tient had an increased platelet count. Here are the possible causes of increased platelet count :
-
Relative Thrombocytosis
A. Anemia (haemolytic)
B. Bacteria,bleeding(Post Hemorrhagic)
C. Connective tissue disease, Cance
D. Damaged tissue (Patient has Injection abcess)
-
- Malignant thrombocytosis
– Primary thrombocythaemia
– Myelofibrosis
– Polycythemia Rubra Vera
– Chronic Myeloid Leukaemia
The above cause (2) was excluded by bone marrow with a result on (21.10.2017) by pathologist Khin Thida Aung with bone marrow showing predominant megakaryocyte.
3rd Treatment
(23.10.2017)
The renal physician suggested urgent
hemodialysis but the patient was not fit to un- dergo neck line hemodialysis due to generalized bleeding. Patient was admitted to the ICU
Renal Function Table 3
Hematology Table 4
(24.10.2017) with the diagnosis of DIC, acute pul- monary oedema and acute renal failure. He ex- pired on the same day.
This case was reported to share the knowledge of DIC: clinical presentation, investigation, complication and treatment.
