From Natalie Shorey, Stago, Inc. Regional Manager, Sydney, Australia:
This clinical case & related question came from the scientists at St George Hospital, one of our teaching hospitals here in Sydney. It prompted some discussion when I put it to other scientists, withour coming to any conclusion so I thought I’d pose the question to you.
A patient has multi organ failure with a grossly elevated ferritin of >99999 ug/mL and the following coagulation profile: prothrombin time (PT), 26.9 s; PT mix, 16.9 s; partial thromboplastin time (APTT) 125 s; APTT mix, 43.8 s ( partial correction), fibrinogen 1.9 g/L; thrombin time (TCT) 87.9 s; D-dimer <20 ng/ml, equivocal lupus, reduced extrinsic and intrinsic factors. Heparin has been excluded as a cause of the elevated APTT. Can the extremely high ferritin level be the cause or someway be attributed to the prolonged APTT?
Hello, Natalie, and thank you for your question, which I’ve distributed to several hematologists whose expertise is in hematology as well as coagulation. I received this response from Mary Ann McLane, PhD, University of Delaware: “Ferritin is stored in the liver, so were any liver studies done? It is also released significantly into the circulation in inflammation, almost making it a marker of that condition… if that helps.”
I believe Dr. McLane is on the right track; given there is no heparin, these results seem to partially support moderate to severe liver disease with loss of coagulation factor production. The low normal fibrinogen level seems to indicate advanced liver disease, as in early liver disease fibrinogen and factor VIII levels rise. It would be interesting to see the liver enzyme panel results.
A lit search reveals there is but one publication, Naithani R, Chandra J, Narayan S, Sharma S, Singh V. Thalassemia major– on the verge of bleeding or thrombosis? Hematology. 2006;11:57-61 that finds a weak positive correlation (r=.382) between ferritin and the PT but not with PTT. Let’s see what other colleagues have to say!