On the thin red line … between thrombosis and bleeding

Introduction: Idiopathic thrombocytopenic purpura is defined as a hematological disorder defined by isolated thrombocytopenia without a clinically apparent cause determined by autoimmune mechanism, usually asymptomatic or presented with bleeding.
Case presentation: We are presenting the case of a 54 year old female patient, diagnosed at an early age with idiopathic thrombocytopenic purpura, treated for many years with steroids. The onset of complica-tions (diabetes mellitus, hypertension, cataract) moti-vated stopping the treatment, followed by splenectomy and therapy with Emplate. She has a history of both thrombotic (deep venous thrombosis, pulmonary em-bolism) and hemorrhagic events (metrorrhagia) and is admitted in our service 7 hours after the onset of an acute retrosternal chest pain. On admission, the elec-trocardiogram suggested acute extensive anterior myo-cardial infarction, with complete right bundle branch block. The laboratory parameters showed elevated bi-ochemical markers for myocardial infarction and mild thrombocytopenia (95000/mmc).The left ventricle had normal size, but severely impaired global systolic func-tion (EF 30%) due to extended wall motion abnorma-lities. The emergency coronary angiography identified thrombotic occlusion of left anterior descending ar-tery, followed by primary angioplasty with drug eluting stent. Drop of platelet count motivated cessation of he-parin treatment and therapy with Aspirin and Ticagre-lor. Subsequent platelet drop (to 50000/mmc) justified Dexamethasone pulse therapy. 72 hours after admissi-on, the patient experienced recurrence of intense chest pain associated with electrocardiographic abnormaliti-es consistent with acute stent thrombosis, confirmed by the emergency angiography, which required thrombus aspiration. A multidisciplinary team (cardiologist, in-terventional cardiologist, hematologist) decided treat-ment with Aspirin 75 mg, Clopidogrel 150 mg and Nadroparine. The constant thrombocyte count decre-ase (to 4000/mmc) justified treatment with only 75 mg of Clopidogrel and replacement of Nadroparine with Fondaparinux, with no hemorrhaging events or hemo-globin drop. The occurrence of thrombotic events in a patient with apparent high hemorrhagic risk raises the suspicion of an associated prothrombotic coagulopathy (thrombophilia), which needs further investigations. One month after the coronary event, the pacient is hemodynamically stable, with no hemorrhaging events, but severe persistent thrombocytopenia.
Conclusions: Due to the association of reccurent thrombotic events, but also high risk of bleeding, this patient with idiopathic thrombocytopenic purpura is a real therapeutic challenge requiring multidisciplinary approach and constant monitoring.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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