title: Refractory heparin induced thrombocytopenia with thrombosis (HITT) treated with therapeutic plasma exchange and rituximab as adjuvant therapy.
abstract: We report a case of refractory heparin-induced thrombocytopenia with thrombosis (HITT) with prolonged thrombocytopenia and multiple thrombotic complications that failed to improve despite aggressive treatment. A 60 year old female with a prior history of venous thromboembolism was admitted with an acute pulmonary embolism, and developed HITT after several days on heparin therapy. She suffered multiple complications including bilateral venous limb gangrene, acute renal failure, and refractory thrombocytopenia, leading us to use multimodality therapy including therapeutic plasma exchange (TPE) and rituximab immunosuppression. The patient had transient improvements in her thrombocytopenia with TPE, and rituximab was added in an attempt to reduce antibody production. She eventually required bilateral limb amputation, and only after removal of the gangrenous limbs did her platelet count show sustained improvement. We discuss the possible contribution of infection to her prolonged course.
authors: Hematology/Oncology, Department of Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, United States. Electronic address: aschell78@yahoo.com.
authors: Amy M
authors: AM
authors: Schell
authors: Melissa
authors: M
authors: Petras
authors: Zbigniew M
authors: ZM
authors: Szczepiorkowski
authors: Deborah L
authors: DL
authors: Ornstein
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D005260:Female; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D010951:Plasma Exchange; D013921:Thrombocytopenia / Q000139:chemically induced / Q000628:therapy; D013927:Thrombosis / Q000139:chemically induced / Q000628:therapy; D054556:Venous Thromboembolism / Q000188:drug therapy*
chemical_list: D000925:Anticoagulants; D006493:Heparin
keywords: BKA; Corticosteroids; HIT; Heparin induced thrombocytopenia with thrombosis; ODU; Phlegmasia cerulea dolans; Rituximab; TPE; Therapeutic plasma exchange; below-knee amputations; heparin induced thrombocytopenia; optical density units; therapeutic plasma exchange