Disseminated intravascular coagulation (DIC)

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Health and Medicine

Disseminated intravascular coagulation (DIC)

DIC is a condition that is life threatening as it prevents normal blood clotting in human. Though it is a rare condition it might cause hemorrhage throughout the body which may lead to organic failure, shock and death1.

The body’s natural ability to control blood clotting fails to function well in DIC, leading clumping and small blood vessels all over the body get clogged. Clotting excessively causes damage in organs, destroys blood cells, and also makes blood not to clot normally by depleting the supply of platelets and other clotting factors. This condition causes profuse bleeding both internally and externally.

It is not easy to diagnose DIC as it is a very complex condition.DIC does not have a single test for its. In most cases, several tests are repeatedly done over a period for accurate diagnosis. An individual, who experiences excessive bleeding or clotting, may have DIC. Confirmation of DIC can be done by measuring amounts of platelets, prothrombin, fibrinogen and other substances that may affect clotting1.

The tests used to diagnose DIC

D-dimer test measures fibrin, a substance that is released during break up of a blood clot. This test determines whether a person’s blood clotting is normal. In people with abnormal blood clotting, D-dimer levels are always higher.

The next blood test is Prothrombin time (PT/INR) which is done to see how long blood takes to clot. For blood to clot and stop bleeding (coagulation), a dozen of blood proteins are needed. Among several clotting factors produced by the liver is Prothromblin, a long prothrombin time can be a sign of DIC.

Blood smear test is done by smearing a blood drop on a slide staining it with dye and observing through a microscope. Then a record of platelets, the number, size and shape of red blood cells and white blood cells is taken. Blood cells of people with DIC often look damaged.

Next is Fibrinogen test, testing for fibrinogen a protein that plays part in blood clotting. Measurements are taken to check how much fibrinogen is in the blood. A low fibrinogen level happens when the body uses fibrinogen faster than it can make. People with low fibrinogen may be having DIC.

Finally,complete blood count is also done. It involves counting red blood cells and white blood cells from a taken blood sample. DIC cannot be diagnosed by CBS results; this only provides information to aid a doctor main diagnosis. (Drop in platelets count may be caused by DIC)

The tests and their significance

An emergency department received a 37yr old man who had one week history of chills, fever and productive coughs after he became febrile and disoriented. He was found to have purpura, epistaxis, and hematuria on examination. A platelet count of 17,000 cells/micro liters, a white cell count of 42,000 cells/microliters with a shift to the left, a prolonged prothrombin time to 16.5 seconds, a prolonged to 63 seconds of an activated partial thromboplastin, the level of fibrinogen was below 100 mg/dL and the concentration of fibrin degradation products was elevated, this was shown by laboratory test taken. Kidney injury with a serum creatinine level 3.1 mg/dL was shown by metabolic panel. Schistocytes and confirmed thrombocytopenia was revealed by peripheral blood smear. Pleural effusion too was a revelation by the chest radiograph, which was revealed to be an empyema on further evaluation. A surgical consult was obtained for pus drainage and chest tube placement after the patient was admitted to the intensive care unit. To control his bleeding, administration of cryoprecipitate, platelets concentration, and fresh frozen plasma was done; the treatment of infection was started by broad-spectrum antibiotics. His coagulation parameters slowly recovered the next day, and subsequent clinical course was uneventful.

Significance of the test results

The tests results above indicate a complex DIC syndrome and both thrombosis and hemorrhage secondary to underlying conditions are involved. The recognition of underlying conditions in a patient with clinical manifestation of thrombosis or bleeding (or both) and confirmation by repeat measurement of coagulation parameters play a role in diagnosis. The underlying condition can be corrected by mainstay of treatment. Stabilization of the patient in cases with active bleeding can be done by blood component replacement. In certain conditions where thrombotic manifestations predominate, heparin use can be considered though it is controversial (e.g., purpura fulminans, solid tumors, hemangiomas, dead fetus syndrome) 2.

Liver Disease

The liver sever various critical function many bodily functions from protein production and blood clotting to cholesterol, glucose and iron metabolism. The liver can be affected by a variety of illnesses. Occurrence of cirrhosis happens when the normal liver cells are replaced by scar tissue resulting from chronic liver disease. The particular liver disease treatment depends on its specific cause. To evaluate the functionality of the liver, a series of special blood tests can often be done3.

First is Serum bilirubin test which measures the level of bilirubin in the blood. Bilirubin is excreted in the bile and produced by the liver. An elevation of bilirubin levels might indicate an obstructed flow of bile or liver inability to process bile. Serum alkaline phosphatase test measures the level of alkaline phosphate. Many tissues have alkaline phosphate; it is highly concentrated in the liver, biliary tract, and bone. Performance of the test can be done to assess functioning of the liver and detection of liver lesions which may cause obstruction of biliary, tumors or abscesses.

Alanine transaminase (ALT) test checks the level of alanine aminotransferase that is released into the bloodstream after the liver cell is damaged acutely. The performance of the test is to assess liver functions, or evaluation of treatment in acute liver disease like hepatitis. Serum albumin test, on the other hand, determines the level of albumin is in the blood.

Prothromblin time (PT) test measures the time it takes blood to clot whereby prolonged clotting is an indication ofliver disease. Tissue damage in the liver is done through Lactic dehydrogenase test which can facilitate liver disease diagnosis. The 5’-nucleotidase test, which measures 5’-nucleotidase level helps diagnose diseases associated with cholestasis. Elevated levels of 5’-nucleotidase is an indication of liver disease.

Mitochondrial antibodies test targets primary binary cirrhosis, chronic active hepatitis, and other certain autoimmune disorders (which are antibodies), while Aspartate transminase (AST) test targets the levels of aspartate transaminase that is released in the bloodstream after a heart or liver problem. After acute liver cell damage, this enzyme is released into the bloodstream.

Serum alpha-1 antitrypsin test (A1AT) is done to test the levels of alpha-1 antitrypsin in blood. It identifies a rare form of emphysema in adults and rare form of liver disease (cirrhosis) in children and adults. The last test is Alpha-fetoprotein test which detects fetal tissues and tumors, since the two produce alpha-fetoprotein.

Practicality of the test and test score significance

A 22-year-old man patient who is HBsAg(+), HBeAg(+), anti-HBe(-), with a HBV DNA of 71.5 million copies/mL this is approximately 14 million int. Unit/mL and a persistently serum ALT ranging from 20 to 30 int. unit/L(upper limit of normal 40 int/L). He had a normal essential liver biopsy. This would not be treated at this time although his HBV DNA level is high. He has no significant inflammation on liver biopsy and serum ALT that is normal as he is young this is a prediction of low probability of HBeAG seroconversion in both nucleos/tide analog and peginterferon. Though serum HBV DNA level in patience can be decreased by antiviral therapy, no evidence has been shown that treating this patient will improve clinical outcome at this stage. This patient will need continuous treatment for several years or even decades to derive clinical benefit given this low rate of HBeAg seroconversion less than 5% after one year of treatment.

For feasible achievement of this goal, it must be balanced against the risk of drug resistance. There is a possibility that a patient may undergo spontaneous HBeAg seroconversion upon the next few years, Hence the patient has to be followed up and re-examined ALT every 3 to 6 months. In case his ALT becomes more than two times normal, the monitoring of the patient must be more frequent and treatment should commence if no observable changes are recoded in six weeks. For patients above 45 years, with the same high HBV DNA level, the biopsy would be run and a consideration treatment if HBV DNA level persists high or if there is moderation/severe inflammation and/or advancement of fibrosis on biopsy.

References

1. Wallach, J. B. Interpretation of diagnostic tests. Philadelphia: Wolters Kluwer Health/Lippincott Wiliams & Wilkins; 2007.

2. Pagana, K. D., & Pagana, T. J. Mosby’s diagnostic and laboratory test reference. St. Louis, Mo: Mosby; 2013.

3. Friedman, L. S., & Keeffe, E. B. Handbook of liver disease. Philadelphia, PA: Elsevier/Saunders; 2012.