Heparin-induced thrombocytopenia differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Heparin-induced thrombocytopenia}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Heparin-induced_thrombocytopenia]]
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] {{shyam}}


==Overview==
==Overview==
[[Heparin-induced thrombocytopenia]] is diagnosed when the [[platelet]] count falls by > 50% typically after 5-10 days of [[heparin]] therapy. It should be differentiated by other causes of thrombocytopenia like hemolytic uremic syndrome, Thrombotic thrombocytopenia and others.
[[Heparin-induced thrombocytopenia]] is diagnosed when the [[platelet]] count falls by > 50% typically after 5-10 days of [[heparin]] therapy. It should be differentiated by other causes of thrombocytopenia like [[Hemolytic-uremic syndrome|hemolytic uremic syndrome]], t[[Thrombotic thrombocytopenia|hrombotic thrombocytopenia]], [[disseminated intravascular coagulation]], [[post-transfusion purpura]], and [[systemic lupus erythematosis]].


==Differential diagnosis==
==Differential diagnosis==
Diagnosis of [[Heparin-induced thrombocytopenia]] is mainly done with the help of lab tests. A decrease in [[platelet]] count by > 50% typically after 5-10 days of [[heparin]] therapy leads to a diagnosis of [[HIT]]. Thus, it should be differentiated from other causes of thrombocytopenia like


* [[Disseminated Intravascular Coagulation]]
HIT must be differentiated from other diseases that present with thrombocytopenia. Please scroll down to view the table.
* [[Thrombotic Thrombocytopenic Purpura]]
* [[Hemolytic-Uremic Syndrome]]
* [[Immune Thrombocytopenic Purpura]]
* [[Drug-Induced Thrombocytopenia]]
* [[Posttransfusion Thrombocytopenia]]
* [[Systemic Lupus Erythematosus]]
 
The table below summarizes the different findings between HIT and other diseases in the differential diagnosis:
{| class="wikitable"
{| class="wikitable"
! scope="col" | Characteristic/Parameter
! scope="col" | Characteristic/Parameter
! scope="col" | '''HIT'''
! scope="col" | '''HIT'''
! scope="col" | '''DIC'''
! scope="col" | '''DIC'''
! scope="col" | '''HUS'''
! scope="col" | '''HUS'''<ref name="pmid28416508">{{cite journal| author=Jokiranta TS| title=HUS and atypical HUS. | journal=Blood | year= 2017 | volume= 129 | issue= 21 | pages= 2847-2856 | pmid=28416508 | doi=10.1182/blood-2016-11-709865 | pmc=5445567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28416508  }} </ref>
! scope="col" | '''Atypical HUS'''
! scope="col" | '''ITP'''
! scope="col" | '''ITP'''
! scope="col" | '''PTP'''
! scope="col" | '''PTP'''
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|-
|-
! scope="row" | Symptoms
! scope="row" | Symptoms
| Sharp, [[pleuritic]], retro-sternal (under the sternum) or left precordial (left chest) pain.
| [[Bleeding]], [[thrombosis]], [[Necrosis|skin necrosis]]
| Crushing, pressure-like, heavy pain. Described as "elephant on the chest".
| [[Bleeding]], [[thrombosis]], [[petechiae]], [[sepsis]]
| [[Renal failure]], [[hematuria]], [[bleeding]], [[microangiopathic hemolytic anemia]]
| [[Renal failure]], [[hematuria]], [[bleeding]], [[microangiopathic hemolytic anemia]]
| [[Petechiae]], [[bleeding]], other [[autoimmune diseases]]
| [[Petechia]]<nowiki/>e, [[purpura]], [[ecchymoses]]
| [[Bleeding]], [[photosensitivity]], [[arthritis]], [[malar rash]], discoid rash, [[Renal insufficiency|renal failure]], [[seizures]], [[psychosis]]
|-
|-
! scope="row" | Platelet count
! scope="row" | Platelet count
| Pain radiates to the trapezius ridge (to the lowest portion of the [[scapula]] on the back) or no radiation.
| Low but usually more than 20000 per microliter
| Pain radiates to the [[jaw]], or the left or arm, or does not radiate.
| Low
| Low
| Low
| Low; can be as low as 10000 per microliter
| Low; can be less than 10000 per microliter; sudden onset after [[transfusion]]
| Variable; usually low
|-
|-
! scope="row" | PT and PTT
! scope="row" | PT and PTT
| Does not change the pain
| Normal
| Can increase the pain
| Elevated
| Normal
| Normal
| Normal
| Normal
| Usually normal
|-
|-
! scope="row" | Systemic systems
! scope="row" | Etiology
| Pain is worse [[supine]] or upon [[inspiration]] (breathing in)
| [[Heparin]] exposure
| Not positional
| [[Sepsis]], delivery of fetus, [[acute promyelocytic leukemia]], other [[malignancy]]
| [[Escherichia coli O157:H7|E.coli strain O157:H7]]; [[Shiga-like toxin]]
| Dysregulation of [[Complement|complement activation]]; mutation in [[Factor H|complement factor H]]
| Idiopathic; can be secondary to [[chronic lymphocytic leukemia]], [[Human Immunodeficiency Virus (HIV)|HIV]], [[Hepatitis|viral hepatitis]], [[H. pylori]]
| Exposure to transfused products
| Autoimmunity with development of [[antibodies]] to [[DNA]]
|-
|-
! scope="row" | Drug-related
! scope="row" | Drug-related
| Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER
| Yes, always
| Sudden or chronically worsening pain that can come and go in [[paroxysm]]s or it can last for hours before the patient decides to come to the ER
| Possible
| No
| No
| Yes
| No; transfusion-related
| Possible; drug-induced lupus can be caused by medications like [[hydralazine]] or [[isoniazid]]
|-
|-
! scope="row" | Bleeding
! scope="row" | Bleeding
| Does not change the pain
| Possible
| Can increase the pain
| Usually
| Usually
| Usually
| Yes; spontaneous bleeding if [[platelet]] count < 10000 per microliter
| Yes; spontaneous bleeding if platelet count < 10000 per microliter
| Rare
|}
|}
Table legend: '''HIT''', heparin-induced thrombocytopenia; '''DIC''', disseminated intravascular coagulation; '''HUS''', hemolytic-uremic syndrome; '''ITP''', immune thrombocytopenia purpura; '''PTP''', post-transfusion purpura; '''SLE''', systemic lupus erythematosis


==Reference==
==Reference==

Latest revision as of 21:08, 26 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Shyam Patel [3]

Overview

Heparin-induced thrombocytopenia is diagnosed when the platelet count falls by > 50% typically after 5-10 days of heparin therapy. It should be differentiated by other causes of thrombocytopenia like hemolytic uremic syndrome, thrombotic thrombocytopenia, disseminated intravascular coagulation, post-transfusion purpura, and systemic lupus erythematosis.

Differential diagnosis

HIT must be differentiated from other diseases that present with thrombocytopenia. Please scroll down to view the table.

Characteristic/Parameter HIT DIC HUS[1] Atypical HUS ITP PTP SLE
Symptoms Bleeding, thrombosis, skin necrosis Bleeding, thrombosis, petechiae, sepsis Renal failure, hematuria, bleeding, microangiopathic hemolytic anemia Renal failure, hematuria, bleeding, microangiopathic hemolytic anemia Petechiae, bleeding, other autoimmune diseases Petechiae, purpura, ecchymoses Bleeding, photosensitivity, arthritis, malar rash, discoid rash, renal failure, seizures, psychosis
Platelet count Low but usually more than 20000 per microliter Low Low Low Low; can be as low as 10000 per microliter Low; can be less than 10000 per microliter; sudden onset after transfusion Variable; usually low
PT and PTT Normal Elevated Normal Normal Normal Normal Usually normal
Etiology Heparin exposure Sepsis, delivery of fetus, acute promyelocytic leukemia, other malignancy E.coli strain O157:H7; Shiga-like toxin Dysregulation of complement activation; mutation in complement factor H Idiopathic; can be secondary to chronic lymphocytic leukemia, HIV, viral hepatitis, H. pylori Exposure to transfused products Autoimmunity with development of antibodies to DNA
Drug-related Yes, always Possible No No Yes No; transfusion-related Possible; drug-induced lupus can be caused by medications like hydralazine or isoniazid
Bleeding Possible Usually Usually Usually Yes; spontaneous bleeding if platelet count < 10000 per microliter Yes; spontaneous bleeding if platelet count < 10000 per microliter Rare

Table legend: HIT, heparin-induced thrombocytopenia; DIC, disseminated intravascular coagulation; HUS, hemolytic-uremic syndrome; ITP, immune thrombocytopenia purpura; PTP, post-transfusion purpura; SLE, systemic lupus erythematosis

Reference

  1. ↑ Jokiranta TS (2017). "HUS and atypical HUS". Blood. 129 (21): 2847–2856. doi:10.1182/blood-2016-11-709865. PMC 5445567. PMID 28416508.

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