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Increased PT and PTT, decreased platelets and fibrinogen, smear from Figure A
70%
256/365
Increased PT and PTT, increased platelets and fibrinogen, smear from Figure A
8%
29/365
Increased PT and PTT, increased platelets and fibrinogen, smear from Figure B
7%
27/365
Decreased PT and PTT, decreased platelets and fibrinogen, smear from Figure B
6%
22/365
Decreased PT and PTT, increased platelets and fibrinogen, smear from Figure B
1%
5/365
Select Answer to see Preferred Response
This patient's clinical presentation is consistent with disseminated intravascular coagulation (DIC), which presents with an increased PT and PTT, decreased platelets and fibrinogen, and schistocytes on peripheral blood smear (Figure A). DIC is a consumptive coagulopathy that most often occurs in the setting of sepsis, neoplasms, or trauma. Common symptoms and signs include bleeding from venipuncture sites, hematuria, and petechiae. Treatment includes administration of fresh frozen plasma to replenish clotting factors, as well as cryoprecipitate and platelets. Patients often need large amounts of blood products, as administered products are often consumed as part of the ongoing DIC process. There is an increased risk of both bleeding and clotting, and the risk of mortality is high. Gauer and Braun discuss thrombocytopenia. They note that DIC should be considered in the differential diagnosis for pregnant patients with thrombocytopenia, along with thrombotic thrombocytopenia purpura. They also note that fragmented red blood cells (schistocytes) are seen in microangiopathic hemolytic anemias, which include DIC, hemolytic uremic syndrome (HUS), and thrombotic thrombocytopenia purpura (TTP). While all three are life-threatening and management is different for each, a D-dimer assay can guide diagnosis. D-dimer is indicative of fibrinolysis, so it is elevated in DIC, whereas it is normal to mildly elevated in TTP or HUS. Levi et al. discuss the diagnosis and management of DIC. They note that treatment of DIC should be aimed at treatment of the underlying condition. They suggest that blood products should be given in cases of bleeding, and not solely to correct lab abnormalities. Figure A shows a blood smear with both normal red blood cells and schistocytes. Figure B shows a blood smear with normal red blood cells, a lymphocyte (large cell on the left), and a neutrophil (large cell on the right). Incorrect Answers: Answers 2-5: These answers do not reflect typical labs in patients with DIC.
3.6
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