The Real-World Boards: Question #7

A 62-year-old man with sepsis, recent chemo and thrombocytopenia

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A 62-year-old woman with an aggressive B-cell lymphoma has been admitted to your ICU with presumed sepsis after presenting to the ED with malaise, BP 92/54, fever of 38.5˚C, and heart rate 110/min. Her first round of R-CHOP chemotherapy was 2 weeks ago.

No infectious source is identified after an initial workup in the ED, including chest x-ray, urinalysis, and blood cultures.

She has no history of exposure to heparin. Cefepime and vancomycin have been provided along with fluid resuscitation for her relative hypotension.

Labs show:

Scant schistocytes are present on the peripheral blood smear.

You page hematology and are awaiting a callback.

Thrombocytopenia would be expected in this patient after recent R-CHOP. The question is whether another cause is present and whether additional treatments are appropriate.

Myelosuppression from chemotherapy

R-CHOP two weeks prior would be expected to reduce platelet count, and sometimes to this degree (26K). Chemotherapy may be the sole etiology, but concluding this prematurely could miss important contributing causes.

Factor VIII levels are normal or elevated in myelosuppressive thrombocytopenia.

Sepsis-related disseminated intravascular coagulation

From a Bayesian perspective, this is a likely diagnosis. DIC is extremely common in patients with severe sepsis admitted to ICUs. Sepsis-induced coagulopathy has an incidence of 20-50%, while overt DIC may occur in 15-30%. Scant schistocytes are common in DIC.