Bilateral adrenal hemorrhagic infarction complicating heparin-induced thrombocytopenia (HIT).

The patient, a 52-year-old female with serious injuries sustained in a motor vehicle accident, had a high pretest probability for HIT, based upon clinical events that occurred during the first 10 hospital days. The pretest probability score (4 T’s clinical scoring system) was 8 (the maximum score), based upon 55% platelet count fall (2 points) that began on day 5 of heparin therapy and that preceded the second operation (2 points), with thrombotic manifestations (bilateral adrenal infarction and deep-vein thrombosis; 2 points) without other apparent explanation (2 points). The clinical diagnosis was supported by strong positive testing for HIT antibodies (99% serotonin release; normal < 10%; 2.245 optical density units in an in-house anti-PF4/heparin ELISA that detects IgG class antibodies; normal < 0.450 units). Coagulopathy (elevated INR) and leukocytosis were attributed to HIT and the early stages of adrenal crisis, respectively, and both abnormalities resolved with danaparoid anticoagulation and corticosteroids. The patient was switched from prophylactic-dose to therapeutic-dose danaparoid when routine duplex ultrasound detected a subclinical DVT involving a small area of the left femoral and popliteal veins.

Abbreviations: bid, twice-daily; DVT, deep-vein thrombosis; sc, subcutaneous; UFH, unfractionated heparin.