Representing this patient our intention was to stress the importance of monitoring platelet number in patient on heparin therapy. We have, for the first time, in our hospital used reversibile thrombine inhibitor, that showed efficacy in treatening HIT II complications. HIT II immunologicaly caused side-effect of heparin therapy, characterized by decrease in thrombocyte number for more than 50 %, with increased inclination to thromboembolic incidents. The disease most commonly appears 5-10 days after initiation of mainly unfractionated heparin therapy. Application of ’4 T score’ in clinical judgement for HIT probability, and laboratory investigation for presence of anti-heparin antibodies markedly contribute to in time detection and treatment of this illness. If anti-heparin antibodies are detected, heparin application must be stopped immidiately, and must be replaced by some anti-heparin anticoagulant preparation ( Fxa inhibitor, heparinoide, or direct inhibitor of thrombine). In time application of substitutional preparation for heparin markedly diminishes the occurence of thromboembolic complications.
We presented the case of patient hospitalized in our institution by reason of complete thrombosis of left illiac vein, joint femoral vein, deep veins of femoral region, popliteal vein and initial part of great saphenous vein. Treatment started by non-fractionated heparin and continued by warfarin, but the patient developed clinical feature of HIT II, so, current anticoagulant therapy was stopped , and fondaparinux was introduced. Although thrombocyte number increased, D-dimers were in additional rise, and patient developed pulmonary embolism. Reversible thrombin inhibitor argatroban was introduced in therapy in daily dose of 2 μg/kg/min in continual infusion lasting 15 days, followed by continual APTT monitoring,in therapeutic range 1.5-2 times of basic value. Rise in platelet number was monitored, decrease of D-dimer, and local clinical improvement. Marginal recanalization of veins in left femoral region and complete passage of popliteal vein were documented by color doppler.
Further, clinical estimation of HIT II probability using „4T“ graduating system, and laboratory investigation to antiheparin antibodies, had significant role in diagnosis confirmation, and in selecting suitable substitutional preparation for heparin.Prikazom smo željeli naglasiti važnost praćenja broja trombocita kod liječenja heparinom. Uporabili smo po prvi puta reverzibilni inhibitor trombina; koji je pokazao učinkovitost u liječenju komplikacija HIT-a II. HIT II je imunološka nuspojava heparinske terapije praćena trombocitopenijom > 50% i povećanom sklonošću tromboemboliji. Najčešće se javlja 5. do 10. dana terapije nefrakcioniranim heparinom. Otkrivanju i liječenju ove nuspojave značajno pridonosi primjena „ 4T zbira“ i otkirvanje prisutnosti protutijela na heparin. Ukoliko se protutijela dokažu; heparin se isključuje i nastavlja se ne-heparinskim antikoagulansom (inhibitorom FX a; heparinoidom ili direktnim inhibitorom trombina); čime se smanjuje rizik tromboembolije. Prikazali smo slučaj bolesnice s kompletnom trombozom lijeve ilijačne vene; zajedničke femoralne vene; dubokih vena natkoljenice; poplitealne vene i početnog dijela velike vene safene. Liječenje je započelo nefrakcioniranim heparinom i nastavljeno varfarinom. Bolesnica je razvila kliničku sliku HIT-a II. Prekinuta se dosadašnja antikoagulantna terapija i uvoden je fondaparinux. Broj trombocita je počeo rasti; D-dimeri tako|er. Razvila se plućna embolija. Liječenje je nastavljeno reverzibilnim inhibitorom trombina argatrobanom u dnevnoj dozi od 2 μg/kg/min kontinuiranom infuzijom u trajanju od 15 dana. Pratili smo APTV; čije su vrijednosti bile 1.5-2 puta duže od bazične vrijednosti. Broj trombocita je rastao; koncentracija D-dimera se snizila; nastupilo je lokalno kliničko poboljšanje. Obojeni doppler je pokazao rubnu rekanalizaciju vena lijeve natkoljenice i potpunu prohodnost poplitealne vene. Klinička procjena vjerojatnosti HIT II s „4T“ bodovnim sustava otkrivanja heparinskih protutijela imala je značajnu ulogu u potvrdi dijagnoze i odluci o odabiru odgovarajućeg zamjenskog lijeka za heparin
