Thrombosis with Thrombocytopenia - A Vascular Paradox

BACKGROUND Thrombosis associated with thrombocytopenia is a vascular paradox which we seldom encounter in our clinical practice. We hereby describe four real world clinical situations and their therapeutic management. Since there are no guidelines regarding this subset, most of the treatment is based on few anecdotal reports and consensus data. Hence, we have reviewed the literature to throw light on some pertinent clinically relevant questions. Our objective is to describe and discuss the probable reasons of vascular paradox and its management. METHODS It is a descriptive study of four cases collected over one-year period including patients of thrombosis with thrombocytopenia. RESULTS In the first case, the patient had pulmonary embolism as a presenting manifestation of leukaemia. Only 5 % cases of AML-M3 sub type acute promyelocytic leukaemia present with normal peripheral blood smear. Patient had thrombocytopenia with deep vein thrombosis and pulmonary embolism. In the second case, secondary antiphospholipid antibody syndrome (APLS) presented with ilio-femoral deep vein thrombosis associated with thrombocytopenia and bleeding tendency. In the third case, antiphospholipid antibody syndrome with thrombocytopenia was associated with severe pulmonary hypertension and deep vein thrombosis. In the fourth case, patient presented with non-ST elevation myocardial infarction (NSTEMI) with thrombocytopenia. He was diagnosed with idiopathic thrombocytopenic purpura. He had angiographic evidence of critical triple vessel disease. He was treated with coronary bypass surgery after initiating treatment with oral eltrombopag and steroids. CONCLUSIONS We have highlighted four clinical situations ranging from frank malignancy to pure vascular pathology, where we have encountered and tackled the vascular paradox of ‘thrombosis and thrombocytopenia’ and reviewed the literature pertaining to these case scenarios. KEYWORDS Thrombosis with Thrombocytopenia, APLS, AML-M3, Pulmonary Hypertension, ITP