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Learning CenterMonday, December 1, 2008
December Case Study
After a large holiday meal and falling asleep watching television your sedentary, obese cousin wakes up with severe pain in his right calf. He tries to walk off the pain, but it persists. The site is red and hot, clearly inflamed. This continues and it is decided to take him to the hospital. Since it is a holiday the emergency room is very busy, with a skeleton crew.
Upon examination, the resident looks at the situation and suspects a DVT. Since getting imaging will be a while,(due to the holiday) he immediately decides to give the patient a dose of unfractionated heparin. Several hours after the heparin is given, blood is drawn. Your cousin wants to go home, but they are afraid he will get a PE, so they wait for test results. (It is a holiday...) They give another dose of heparin. The results were as follows: PT= 11.4 sec APTT = 62.8 sec Fibrinogen = 525 Platelets= 657, 000 D dimer = 786 FEU APCR = negative LA = negative Protein C= 78% (80-120%) Protein S = 48% (65-135%) He was admitted due to a Protein S deficiency- Is this correct, and what is the next course of action?
posted by Donna Castellone at
10:02 PM
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the patient will develop thrombosis due to inefficacy to deactivate activated factors v and viii
Most likely the pain in the leg is caused by a DVT- giving a dose of heparin is to prevent that DVT from migrating to the lung and becoming a PE. As far as admiting the patient due to a Protein S deficiency, that is most likely not the cause. The APTT is prolonged, due to the heparin, heparin also will decrease Protein S and C. Testing patients for hypercoaguable states while on anticoagulation is not recommended.
Diagnosis: DVT
Cause: Obesity, Sedentary, possible Genetic Mutation
Some Protein S kits (for example Stago's StaClot PS) have heparin neutralizer in the reagent so that patient's receiving therapeutic amounts of heparin may still be tested. We always run a heparin level if we suspect a low PS might be due to heparin (to make sure it is not >1.0 IU/ml that our reagent can theoretically handle. Another problem with testing for Protein S in the acute phase is the influence of high levels of Factor VIII on clotting-based assays. We always run a Factor VIII when we get an unexpected low PS. Add this to possible consumption of Protein S in an acute thrombotic event, and there is more than one reason for this "acquired Protein S deficiency". We'd recommend repeat testing at a time remote from the acute event.