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Case Study of a 62-year-old Female with Postoperative Bleeding and Persistent Abnormalities on Platelet Aggregation Studies
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Case Study of a 62-year-old Female with Postoperative Bleeding and Persistent Abnormalities on Platelet Aggregation Studies

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  • 27 oktober 2024
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Voorbeeld van de inhoud

1



Case Study of a 62-year-old Female with Postoperative Bleeding and
Persistent Abnormalities on Platelet Aggregation Studies.


Case Presentation



A 62-year-old female presented with a concerning palpable mass in her right breast in January

2008. The patient elected to undergo a lumpectomy, which was followed by a right modified

radical mastectomy and axillary lymph node dissection. The right breast mastectomy was

complicated by post-operative bleeding requiring transfusion of 1 unit of packed red blood cells

(ISTH-BAT score 4). The patient’s past medical history was significant for easy bruising (ISTH-

BAT score 1), frequent nosebleeds (ISTH-BAT score 1), heavy menstrual periods (ISTH-BAT

score 1) and a history of a hematoma of the left thigh following an injury (ISTH-BAT score 1).

The patient’s total ISTH bleeding score was 8 (normal range is <4 in adult males, <6 in adult

females and <3 in children).


Her family history was significant for easy bruising and frequent nosebleeds in her mother. The

patient had no siblings or children. The only medication the patient was taking was

levothyroxine (Synthroid) and her TSH was normal. She was not taking antiplatelet medication

or over the counter medications.


Due to her history of increased mucocutaneous bleeding symptoms, perioperative bleeding

requiring blood transfusion, high ISTH bleeding score and family history she underwent

laboratory testing in March 2008 which included a CBC with platelet count, peripheral blood

film, prothrombin time (PT), activated partial thromboplastin time (aPTT), von Willebrand


1

,2


profile and closure times with collagen/ADP and collagen/EPI, all of which were normal.

Platelet aggregation studies by light transmittance aggregometry on platelet rich plasma were

abnormal with ADP only (Table 1). Repeat platelet aggregation studies in April 2008 (Table 2)

demonstrated persistent abnormalities on platelet aggregation studies with ADP only, but

adenine nucleotide testing for delta-storage pool deficiency was normal. Following persistent

abnormalities on platelet aggregation studies, the diagnosis of a platelet function defect was

rendered, however whether the disorder was inherited or acquired was not discernible. She had

no spontaneous bleeding and was not planning any surgeries. She was recommended to be

reevaluated prior to surgeries in the future.


In January of 2024, the patient returned for care with an anticipated fistulectomy and hip

replacement in the future. Her previously diagnosed hypothyroidism was well controlled, and she

denied any episodes of spontaneous bleeding. Of note, the patient underwent an incision and

drainage for a perianal abscess and recovered successfully without any post-operative bleeding

complications. Due to her anticipated need of multiple surgical procedures and her history of

qualitative platelet dysfunction, she was referred to hematology. Repeat platelet aggregation

study results were similar to those previously done in 2008 with decreased platelet aggregation

response to ADP only (Figure 1) and adenine nucleotide ratio was again normal. Patient samples

were sent for platelet granule storage and release testing by flow cytometry (Table 3).




2

, 3




3

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