I’m [Geo] seeking comments about this case of a 65-YOA female on no anticoagulant with retinal hemorrhage and no other bleeding symptoms:
| Coag | 1/18/24 | 1/19/24 | 1/20/24 | 1/21/24 |
| PT | 16.9 | 15.6 | ||
| PTT | 53 | 44 | ||
| TCT | 17 | |||
| FG | 592 | 576 | ||
| FII | 83 | |||
| FV | 79 | |||
| FVIII | 167 | |||
| FIX | 71 | |||
| FX | 75 | |||
| FXI | 80 | |||
| VWF:Ag | 121 | |||
| VWF:RCo | 147 | |||
| D-dimer | 711 | |||
| PTT Mix | ||||
| PTT Control | 29 | |||
| PTT Patient | 52 | |||
| PTT Mix | 38 | |||
| PTT Interp | Uncorrected | |||
| LAC | ||||
| PTT–LA | Prolonged | |||
| StaClot | Negative | |||
| DVV Screen | Negative | |||
| Heme | ||||
| WBC | 3.50 | 2.83 | 4.14 | |
| RBC | 3.18 | 2.93 | 2.96 | |
| HGB | 9.2 | 8.2 | 8.7 | |
| HCT | 27 | 24 | 25 | |
| MCV | 84 | 84 | 84 | |
| MCH | 29 | 29 | 29 | |
| MCHC | 35 | 35 | 35 | |
| PLT | 143 | 140 | 152.5 | |
| Chem | ||||
| Na | 125 | 126 | 125 | |
| K | 3.6 | 4.2 | 4.1 | |
| Ca | 9.4 | 8.2 | 8.5 | |
| Gluc | 98 | 104 | 73 | |
| Creat | 1.2 | 1.1 | 1.3 | |
| EGFR | 51 | 56 | 46 | |
| Alk Phos | 95 | |||
| ALT | 14 | |||
| AST | 39 |
Please provide your comment below.
First thoughts [with thanks from Geo] from Bob Gosselin: My first inclination is the retinal hemorrhage may/may not be related to coagulopathy. The prolongation without correction suggests an inhibitor, although it is unclear what method was used to determine “uncorrected.” Presumably, you have ruled out any medication causes, including lipoglycopeptide antibiotics or DOACs.
I have, in my olden days, seen abhorrently elevated PT and/or APTT in bleeding patients with normal factor levels (inc VWF) with associated gammopathies. Modestly low PLT count, has MGUS been ruled out? Cause for slightly mild thrombocytopenia? Does she have high blood pressure? Diabetes? Any other blood cell dyscrasia?
From Geo: no DOACs. An anti-Xa returned <0.1. There was a differential comment of burr cells and ovalocytes but no semiquantitative note [1+, 2+, 3+, 4+]. Albumin and total protein were normal, with no electrophoresis reported.
By phone from Dr. Larry Brace: The severe normocytic/normochromic anemia and moderately reduced WBC hint at hypoproliferative bone marrow. Could that be related to the moderately reduced kidney function?
By phone from Dave McGlasson: perhaps outside the box, could retinal bleeding and prolonged PT and PTT indicate a platelet function disorder affecting coag pathway?
From Drs. Mayukh Sarkar and Michael Laposata: Is it possible that this woman is having thrombi that then transform into hemorrhages. The prolonged PTT looks like a lupus anticoagulant, a weak one maybe. That’s what would make me think more along the lines of pro-thrombotic. The elevated fibrinogen reflects the process stimulating the acute phase response, and there are many options for this stimulus.
Difficult to comment when assessing results from other labs without normal ranges listed, and unclear methods. A few comments: 1. no FVII or FXII testing, so possible that prolonged PT and APTT could be due to (mild) deficiencies of these (albeit unlikely)?; 2. mixing did not correct and PTT–LA prolonged – theoretically could be a lupus anticoagulant affecting only APTT, but unclear if the prolonged PTT–LA is just mirroring the general prolonged PTT; 3. FII is normal, so not likely to be LA-hypoprothrombinemia syndrome; 4.aberrant blood workup – could be pointing to a malignancy? MGUS? Paraprotein? 5.Aberrant coags and bleeding could be unrelated and just co-incident.