Name:
A 27-Year-Old with Post-Partum Hemiparesis
Description:
A 27-Year-Old with Post-Partum Hemiparesis
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T00H06M00S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
CATHY: Welcome to Episode 15: A 27-year-old with Post-Partum Hemiparesis.
CHARLIE: Here's the question. A 27-year-old previously healthy woman is brought to the emergency department three days after the delivery of a healthy, full term infant, having presented with new, right hemiparesis and a blue left hand. Physical examination is also notable for diffuse livedo reticularis.
CATHY: Let me stop you right there. So, one, this woman is obviously having a stroke. The right-sided hemiparesis and a blue left hand really points to arterial thrombosis, and in this case it would be involving the arteries of the arms and the cerebral vasculature. Livedo reticularis, which is also the mottling or purplish discoloration of the skin, is also caused by obstruction of capillaries by thrombi.
CHARLIE: Why make that distinction that this is an arterial thrombosis?
CATHY: Well, arterial thrombosis is initiated differently than venous thrombosis, although they do share some common risk factors like older age, obesity and cigarette smoking. Arterial thrombosis is primarily initiated by activation of the platelets. In thinking about the most common cause of this in the United States, it really would be heart attacks or coronary artery disease. Venous thromboembolism, on the other hand, is primarily initiated by vascular injury, which exposes tissue factor to blood components, which activate the coagulation cascade and lead to clot.
CATHY: There aren't that many causes or arterial thrombosis, and they aren't the same as what causes DVT so it's important to make that distinction. Let's get back to the question though. Tell me more about the case.
CHARLIE: Okay, we have a woman here, three days post-partum who presents with a stroke and a blue left hand. In the emergency department she is afebrile, she has a blood pressure of 135 over 80, a regular heart rate of 85 per minute, and a respiratory rate of 18 per minute with a normal oxygen saturation. Her initial laboratories are notable for a white blood cell count of 10.2, a hematocrit of 35%, and a platelet count of 13,000. Her BUN is 36mg per dl, and her creatinine is 2.3mg per dl.
CHARLIE: During her recent admission for childbirth her laboratories were normal. Although this pregnancy was uneventful, her three prior pregnancies resulted in early losses. So Cathy, what additional thoughts do you have now that you have more information?
CATHY: So, like we summarized, we have a 27-year-old, three days post-partum with arterial thrombi. There's nothing else on the history or presentations to suggest a cause of embolic events, like A-fib, or atrial fibrillation, or endocarditis. Based on the lab, she has mild anemia, severe thrombocytopenia and acute kidney injury. Do we have a peripheral smear?
CHARLIE: The peripheral smear shows thrombocytopenia and no evidence of schistocytes.
CATHY: Okay, so putting this all together with her history of lost pregnancies and the constellation of findings associated with this pregnancy, this really points to antiphospholipid syndrome. That can cause all of the findings that were mentioned above, but there are other disorders on the differential and a few different ways to think about this. Considering the clotting history in the current labs, I would be most concerned about antiphospholipid syndrome. Fortunately, there's lab testing that can help us confirm or eliminate this as a diagnosis.
CHARLIE: So, that gets us to the question, which reads: "Which of the following studies will best confirm the underlying etiology of her presentation?" Option A is anti-cardiolipin antibody panel; Option B is an anti-nuclear antibody, or ANA; Option C is Doppler examination of her left arm arterial tree; Option D is echocardiography; and option E is MRI of her brain.
CATHY: To evaluate for antiphospholipid syndrome, the best lab testing is with anti-cardiolipin antibody screening panel, or choice A. This looks for evidence of antibodies directed against cardiolipin and beta-2 glycoprotein. Additional testing for lupus anticoagulant can be determined by clotting assays, such as the Russell viper venom time, the false-positive rapid plasma reagin, and the APTT, or activated partial thromboplastin time.
CHARLIE: What do you think of the other choices, and why are they less useful in this patient?
CATHY: Well, ANA is non-specific, so that alone won't help you diagnose APS, or antiphospholipid syndrome. Doppler examination of the left arm arterial tree and MRI of the brain may show presence of thrombosis, which is likely in this case. But it doesn't diagnose the underlying cause. Again, in this case we suspect it's antiphospholipid antibody syndrome, and these aren't helpful for that diagnosis. Echocardiogram would be done if you suspected there was a structural cause of the diffuse clotting. An example of that would be if you were looking for endocarditis.
CATHY: But again, this is less likely in this case, based on the history and physical that you presented before.
CHARLIE: So, your point is that in this case not only do we have to address the acute symptoms of stroke, and arterial thrombosis, but without addressing the underlying disease, we're really not going to correct the problem overall.
CATHY: Yes, exactly. So, making an accurate diagnosis is going to be critical, but we also want to get the hematologists and interventionalists involved immediately. There may be mechanical approaches to addressing the stroke and the hand ischemia, and we really want those specialists involved early. With the acute clot, anticoagulation would also need to be started immediately. But in this case, we have to be very cautious, because of the severe thrombocytopenia.
CHARLIE: The teaching point in this case is that the mechanism and the cause of arterial thrombosis is different than that of venous thromboembolism, and we need to think of the differential and choose appropriate treatments based on the clinical presentation.
CATHY: And for more information, you can read about this in Harrison's chapter on arterial and venous thromboembolism and the chapter on antiphospholipid syndrome. ♪ (music) ♪