Case 1105 - An Elderly Man with Acute Thrombocytopenia Requiring Cardiac Transplantation

Contributed by Mason Marshall, DO and Irina Chibisov, MD


An elderly male with a past medical history of congestive heart failure (ejection fraction of 10-15%), diabetes, and hypertension presented to the emergency department with shortness of breath and bilateral lower extremity swelling. An EKG and troponin assay were performed in the emergency department and were negative for acute ischemic changes. His BNP was elevated at 4,549 pg/ml, and a chest X-ray revealed bilateral pleural effusions with cardiomegaly, consistent with exacerbation of his congestive heart failure. He was started on diuretics and admitted to the hospital. Enoxaparin 40 mg subcutaneous injections daily were started for DVT prophylaxis. The patient was subsequently recommended for cardiac transplantation due to a low cardiac index. During his hospital stay and work-up for cardiac transplantation he developed thrombocytopenia.

His platelet count upon admission was 156,000/ml. It decreased to 91,000/ml one week later. (Table 1) Since the patient was on enoxaparin for DVT prophylaxis, heparin induced thrombocytopenia was suspected and hematology was consulted. Bilateral upper and lower extremity Doppler ultrasound studies were negative for DVT. The patient's 4T score was calculated to be 4 conferring intermediate risk for HIT. Testing for Heparin PF4 antibodies (HPF4) by enzyme immunoassay (EIA) and serotonin release assay (SRA) were ordered. Enoxaparin was discontinued and fondaparinux was started for DVT prophylaxis.

Table 1. Patient's platelet counts during the first week of hospitalization.


Hospital Day 7:



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