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The Zebra in the room
Grace Lee
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G. Lee (&) Duke University
, DUMC 3841,
Durham, NC 22710, USA
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Heparin induced thrombocytopenia (HIT) is an
immunemediated prothrombotic disorder which classically presents
with declining platelet counts 510 days after heparin
exposure. Thrombotic complications occur in an estimated
2050% of patients with thrombocytopenia and can affect
both the venous or arterial circulation [1]. In patients with a
classic presentation of thrombosis in the setting of
thrombocytopenia, the diagnosis of HIT is readily made.
However, in patients with complicated medical issues and
atypical presentations, the diagnosis is more challenging.
Rarely, HIT presents with unusual manifestations: adrenal
hemorrhagic necrosis, skin necrosis at heparin injection
sites, warfarin-associated venous limb gangrene, cerebral
venous thrombosis, disseminated intravascular coagulation,
or systemic reactions with heparin administration. Often,
these unusual sequelae are not accompanied by
thrombocytopenia (as with skin necrosis), or paradoxically, are
associated with a hemorrhagic event (as a consequence of
thrombosis) [2].
In this issue, Thota et al. describe a patient with HIT
presenting with hemodynamic collapse as a result of adrenal
insufficiency caused by adrenal vein thrombosis and adrenal
necrosis. Although adrenal hemorrhagic necrosis is a very
rare complication of HIT, the authors recognized that the
patient was thrombocytopenic after receiving
low-molecular-weight heparin and that adrenal hemorrhage, as a result
of adrenal vein thrombosis, is frequently associated with
HIT [3].
This case highlights the importance of recognizing the
unusual thrombotic complications of HIT. Although the
diagnosis of HIT can be difficult, recognition of the
unusual sequelae of HIT allows for prompt diagnosis and
initiation of therapy, with potential to prevent significant
morbidity and mortality.
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