Advanced Gastric Cancer Associated with Disseminated Intravascular Coagulation Successfully Treated with 5-fluorouracil and Oxaliplatin

Lee, Dong Seok,Yoo, Seung Jin,Oh, Ho Suk,Kim, Eun Jung,Oh, Kwang Hoon,Lee, Sang Jin,Park, Jong Kyu,Ahn, Yong Chel,Eom, Dae-Woon,Ahn, Heui June The Korean Gastric Cancer Association 2013 Journal of gastric cancer Vol.13 No.2

Gastric cancer patients with acute disseminated intravascular coagulation experiences a rare but severe complication resulting in a dismal prognosis. We report a case of advanced gastric cancer complicated with disseminated intravascular coagulation with intractable tumor bleeding which was successfully treated with chemotherapy consisting of 5-fluorouracil and oxaliplatin. The patient was a 63-yearold man who complained of abdominal pain, melena, and dyspnea on 24 November 2010. We diagnosed stage IV gastric cancer complicated by disseminated intravascular coagulation. Gastric tumor bleeding was not controlled after procedures were repeated three times using gastrofiberscopy. With the patient's consent, we selected the 5-fluorouracil and oxaliplatin combination chemotherapy for treatment. After one cycle of 5-fluorouracil and oxaliplatin therapy, symptoms of bleeding improved and the disseminated intravascular coagulation process was successfully controlled. The primary tumor and multiple metastatic bone lesions were remarkably shrunken and metabolically remitted after eight cycles of chemotherapy. In spite of progression, systemic chemotherapy is effective in disease control; further, the patient gained the longest survival time among cases of gastric cancer with disseminated intravascular coagulation.

Advanced Gastric Cancer Associated with Disseminated Intravascular Coagulation Successfully Treated with 5-fluorouracil and Oxaliplatin

이동석,안희준,유승진,오호석,김은정,오광훈,이상진,박종규,안용철,엄대운 대한위암학회 2013 Journal of gastric cancer Vol.13 No.2

Gastric cancer patients with acute disseminated intravascular coagulation experiences a rare but severe complication resulting in a dismal prognosis. We report a case of advanced gastric cancer complicated with disseminated intravascular coagulation with intractable tumor bleeding which was successfully treated with chemotherapy consisting of 5-fluorouracil and oxaliplatin. The patient was a 63-yearold man who complained of abdominal pain, melena, and dyspnea on 24 November 2010. We diagnosed stage IV gastric cancer complicated by disseminated intravascular coagulation. Gastric tumor bleeding was not controlled after procedures were repeated three times using gastrofiberscopy. With the patient’s consent, we selected the 5-fluorouracil and oxaliplatin combination chemotherapy for treatment. After one cycle of 5-fluorouracil and oxaliplatin therapy, symptoms of bleeding improved and the disseminated intravascular coagulation process was successfully controlled. The primary tumor and multiple metastatic bone lesions were remarkably shrunken and metabolically remitted after eight cycles of chemotherapy. In spite of progression, systemic chemotherapy is effective in disease control;further, the patient gained the longest survival time among cases of gastric cancer with disseminated intravascular coagulation.

Decreased thrombomodulin mRNA expression on peripheral monocytes in disseminated intravascular coagulation patients relates to poor outcomes: The ex vivo effects of lipopolysaccharide and thrombin on monocyte thrombomodulin and CD14 mRNA

Hong, S.K.,Kim, J.E.,Han, K.S.,Kim, H.K. Pergamon Press ; Elsevier Science Ltd 2013 Thrombosis research Vol.132 No.3

Background: Monocytes express substantial amounts of thrombomodulin, which is consumed throughout ongoing thrombin generation. The modulation of thrombomodulin may aggravate intravascular fibrin deposition and the clinical course of disseminated intravascular coagulation (DIC). Although thrombomodulin restoration has received considerable attention, no reports have been published on the in vivo expression status of thrombomodulin. CD14 expression on monocytes is important for regulation of the inflammatory response. We used an ex vivo stimulation study to evaluate the association of the levels of monocyte-expressed thrombomodulin and CD14 messenger RNA (mRNA) with the severity and prognosis of disseminated intravascular coagulation. Methods: A total of 78 patients with suspected DIC were enrolled. Thrombomodulin and CD14 mRNA levels were measured in peripheral blood by real-time quantitative reverse-transcription polymerase chain reaction. Thrombomodulin and CD14 mRNA were also assessed in ex vivo cultures of peripheral whole blood that were stimulated by lipopolysaccharide or thrombin. Results: The levels of monocyte-expressed thrombomodulin mRNA were significantly lower in the non-survivors than in the survivors. A low level of monocyte-expressed thrombomodulin mRNA was a significant prognostic marker, but CD14 did not possess prognostic power. Monocyte-expressed CD14 mRNA correlated significantly with the severity of DIC in survivors. In addition, stimulation of ex vivo cultures of whole blood demonstrated that thrombin upregulates both thrombomodulin and CD14 mRNA, and lipopolysaccharide downregulates thrombomodulin mRNA. Conclusions: The downregulation of thrombomodulin on monocytes reflects the decompensated status of physiological defenses against hypercoagulopathy and represents the poor prognosis in DIC. The expression levels of thrombomodulin on monocytes may be a useful marker to screen for candidates eligible for recombinant thrombomodulin therapy in future.

Changes in Plasma Levels of Natural Anticoagulants in Disseminated Intravascular Coagulation: High Prognostic Value of Antithrombin and Protein C in Patients with Underlying Sepsis or Severe Infection

최규태,홍기호,김지은,김현경 대한진단검사의학회 2014 Annals of Laboratory Medicine Vol.34 No.2

Background: Dysfunctional natural anticoagulant systems enhance intravascular fibrin for- mation in disseminated intravascular coagulation (DIC), and plasma levels of natural anti- coagulants can be used in the diagnosis and prognosis of DIC. Herein, the diagnostic value of 4 natural anticoagulants was assessed, and the prognostic value of antithrombin and protein C were validated in a large population. Methods: Part 1 study included 126 patients with clinically suspected DIC and estimated plasma levels of 4 candidate anticoagulant proteins: antithrombin, protein C, protein S, and protein Z. Part 2 comprised 1,846 patients, in whom plasma antithrombin and protein C levels were compared with other well-known DIC markers according to the underlying dis- eases. The 28-day mortality rate was used to assess prognostic outcome. Results: Antithrombin and protein C showed higher areas under the ROC curve than pro- tein S and protein Z. In part 2 of the study, antithrombin and protein C levels significantly correlated with DIC score, suggesting that these factors are good indicators of DIC severity. Antithrombin and protein C showed significant prognostic power in Kaplan–Meier analyses. In patients with sepsis/severe infection, antithrombin and protein C showed higher hazard ratios than D-dimer. Platelet count showed the highest hazard ratio in patients with hemato- logic malignancy. In patients with liver disease, the hazard ratio for antithrombin levels was significantly high. Conclusions: Decreased plasma anticoagulant levels reflect florid consumption of the phys- iologic defense system against DIC-induced hypercoagulation. Plasma antithrombin and protein C levels are powerful prognostic markers of DIC, especially in patients with sepsis/ severe infection.

Clinicopathologic features and clinical outcomes of gastric cancer that initially presents with disseminated intravascular coagulation: A retrospective study

Rhee, Jiyoung,Han, Sae‐,Won,Oh, Do‐,Youn,Im, Seock‐,Ah,Kim, Tae‐,You,Bang, Yung‐,Jue Blackwell Publishing Asia 2010 Journal of Gastroenterology and Hepatology Vol.25 No.9

<P><B>Abstract</B></P><P><B>Background and Aim: </B> Few systematic studies have been published on prognosis and clinical outcome of gastric cancer patients with disseminated intravascular coagulation (DIC) as the first presentation of malignancy. We evaluated the clinicopathologic features and clinical outcomes of this population.</P><P><B>Methods: </B> We reviewed the medical records of patients with metastatic or recurred gastric cancer that initially presented with DIC.</P><P><B>Results: </B> Twenty‐one patients were included. Median age was 47 years (range, 24–72 years). Eighteen patients (85.7%) had bone metastasis, and nine patients (42.9%) had hemorrhagic complication of DIC. Fourteen patients received palliative chemotherapy, and seven patients received best supportive care (BSC). The most common factor influencing the decision to abandon the palliative chemotherapy was uncontrolled bleeding (57.1%). The median overall survival (OS) of all patients was 58 days (range, 2–342 days). The OS was significantly shorter in BSC than in the chemotherapy group (median, 16 <I>vs</I> 99 days, <I>P</I> < 0.001). In multivariate analysis, chemotherapy was independently associated with longer OS. In the chemotherapy group, the response to treatment was evaluable in 11 patients: two (18.2%) had a partial response, five (45.5%) had stable disease and four (36.4%) had progressive disease. The OS of patients with progressive disease was significantly longer in the chemotherapy group than in the BSC group (median, 92 <I>vs</I> 16 days, <I>P</I> = 0.009).</P><P><B>Conclusions: </B> The prognosis is poor with gastric cancer that initially presents with DIC but palliative chemotherapy, compared with BSC, prolongs OS. Therefore, early and intensive management for correctable DIC followed by chemotherapy should be considered in this population.</P>

Outcome of Disseminated Intravascular Coagulation without Documented Antiphospholipid Antibody Successfully Treated with Rituximab

Hyunkyung Park,Jeonghwan Youk,Seongcheol Cho,Ji Hyun Lee,Yeonjoo Choi,Youngil Koh 순천향대학교 순천향의학연구소 2015 Journal of Soonchunhyang Medical Science Vol.21 No.2

Catastrophic antiphospholipid syndrome (APS) is defined as a rare, life-threatening autoimmune disorder leading to multiorgan failure. Probable APS, with clinical manifestations similar to APS without antiphospholipid antibodies, was suggested to be seronegative catastrophic APS. The triggering factors of catastrophic APS are various, including infection, trauma, malignancy, and surgery. In approximately 40% of patients, catastrophic APS develops from an unknown cause. We report a case of seronegative catastrophic APS due to an unknown origin. A 20-year-old man presented with cough, abdominal pain, skin lesions, tunnel vision, and watery diarrhea without fever. His symptoms and laboratory test suggested disseminated intravascular coagulation. Considering seronegative catastrophic APS, we treated with intravenous steroid and intravenous immunoglobulin, but the effects were limited. After weekly treatment with rituximab, an immune-modulating agent, his laboratory findings including thrombocytopenia and coagulation tests, returned to normal. We conclude that rituximab can be an effective treatment for seronegative catastrophic APS.

파종성혈관내응고를 동반한 분만 후 출혈에 대한 경도관동맥색전술: 결과 평가

안은정,김영환,권보라,김시형 대한영상의학회 2011 대한영상의학회지 Vol.65 No.6

Purpose: We evaluated the efficacy and predictors of clinical outcome after transcatheter arterial embolization (TAE) for treatment of postpartum hemorrhage with disseminated intravascular coagulation (DIC). Materials and Methods: Of 127 patients who underwent TAE for postpartum hemorrhage, 46 progressed to DIC (group 1), 81 showed normal range hematological parameters (group 2). We retrospectively evaluated etiology, embolization methods and the efficacy of TAE for intergroup comparison Pearson Chi-Square test and logistic regression model. Results: Overall TAE failed to control bleeding in 9 patients in spite of technical success. Lower bleeding control rate was found in group 2 (82.6%) relative to group 1 (98.8%, p = 0.001). And embolization methods were not statistically different between two groups no statistically significant predictors associated with failed hemostasis except the amount of transfusion in group 1. Conclusion: Although bleeding control rate is lower in postpartum hemorrhage with DIC than without DIC, we believe that TAE with correction of DIC is an effective method for postpartum hemorrhage with DIC. 목적: 파종성혈관내응고를 동반한 분만 후 출혈의 치료로서 경도관동맥색전술의 효용성과 결과에 영향을 미치는 인자들에 대해 알아보고자 하였다. 대상과 방법: 분만 후 출혈로 인해 동맥색전술을 시행받은 127명의 환자를 대상으로 하였다. 46명의 환자는 시술 전 파종성혈관내응고(집단 1)로 진행되었고 81명의 환자는 혈액응고검사에서 정상 범위의 수치를 보였다(집단 2). 집단 간의 원인질환, 동맥색전술 방법과 지혈 성공률 등을 후향적으로 평가하였으며 통계학적 분석은 Pearson Chi-Square test와 logistic regression model을 이용하였다. 결과: 기술적인 성공에도 불구하고 9명의 환자에서는 동맥색전술 후에도 출혈이 멈추지 않았다. 지혈 성공률은 집단 2(98.8%)에 비해 집단 1(82.6%)에서 더 낮았다(p = 0.001). 집단 간의 원인질환, 동맥색전술 방법에는 차이가 없었으며 집단 1에서 수혈량을 제외하고 시술 전 통계학적으로 의미 있게 지혈 실패에 영향을 미치는 인자들은 보이지 않았다. 결론: 비록 지혈의 성공률은 파종성혈관내응고집단에서 유의하게 낮았지만, 파종성혈관내응고의 교정을 동반한 경도관색전술은 효과적인 치료법이라 생각된다.

급성신손상으로 인해 발생한 dabigatran 독성

문형호 ( Hyoung Ho Moon ),이승은 ( Seung Eun Lee ),오동준 ( Dong Jun Oh ),조희범 ( Hee Bum Jo ),권기환 ( Ki Hwan Kwon ),김윤진 ( Yoon Jin Kim ),김경수 ( Kyung Soo Kim ),신성준 ( Sung Joon Shin ) 대한임상독성학회 2014 대한임상독성학회지 Vol.12 No.2

Dabigatran is the first oral direct thrombin inhibitor approved by the US Food and Drug Administration (FDA) for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Because dabigatran is excreted mainly by the kidneys, serum levels of dabigatran can be elevated to a supratherapeutic range in patients with renal failure, predisposing to emergent bleeding. We describe the case of a 66-year-old man taking dabigatran 150 mg twice daily for atrial fibrillation and cerebral infarction who presented with hematochezia and disseminated intravascular coagulation. Laboratory evaluation showed a hemoglobin level of 6.3 g/dL, platelets of 138,000/mm3, activated partial thromboplastin time (aPTT) of 10?s, and an international normalized ratio (INR) of 8.17. Colonoscopy showed a bleeding anal fissure. Hemostasis was provided by hemoclips and packed red blood cells and fresh frozen plasma were transfused. Since then, there was no further hematochezia, however, bleeding including oral mucosal bleeding, hematuria, and intravenous site bleeding persisted. At presentation, his serum creatinine was 4.96 mg/dL (baseline creatinine, 0.9 mg/dL). Dabigatran toxicity secondary to acute kidney injury was presumed. Because acute kidney injury of unknown cause was progressing after admission, he was treated with hemodialysis. Fresh frozen plasma transfusion was provided with hemodialysis. At 15 days from admission, there was no further bleeding, and laboratory values, including hemoglobin, partial thromboplastin time, and prothrombin time were normalized. He was discharged without bleeding. After 2 months, he undergoes dialysis three times per week and no recurrence of bleeding has been observed.

유착태반 산모에서 발생한 파종성혈관내응고증 -증례 보고-

김형태,문철신,허현언,김광용,이준학,권영은 대한마취통증의학회 2009 Anesthesia and pain medicine Vol.4 No.3

Placenta accreta is a rare complication of pregnancy with high rates of maternal morbidity and mortality. It is usually discovered when removal of the placenta after delivery is difficult or there is substantial postpartum bleeding. Placenta accreta can be complicated by disseminated intravascular coagulation (DIC) and this increases maternal morbidity and mortality. DIC is characterized by the widespread activation of coagulation, which results in the intravascular formation of fibrin and ultimately thrombotic occlusion of small and midsize vessel. We report a 24-year-old woman with DIC, who developed severe pre- and intraoperative bleeding and massive transfusion during emergent cesarean section.disseminated intravascular coagulation, placenta accreta, postpartum bleeding.

Case Report : Renal artery thrombosis secondary to sepsis-induced disseminated intravascular coagulation in acute pyelonephritis

( Ja Young Lee ),( Hee Chul Nam ),( Boo Gyoung Kim ),( Hyun Gyung Kim ),( Hee Chan Jung ),( Ji Hee Kim ),( Geun Seok Yang ),( Youn Jeong Park ),( Ka Young Kim ),( Yu Seon Yun ),( Young Ok Kim ),( Jiha 대한신장학회 2012 Kidney Research and Clinical Practice Vol.31 No.4

There are some reports of renal vein thrombosis associated with acute pyelone-phritis, but a case of renal artery thrombosis in acute pyelonephritis has not been reported yet. Here we report a case of renal artery thrombosis which developed in a patient with acute pyelonephritis complicated with sepsis-induced disseminated intravascular coagulation (DIC). A 65-year-old woman with diabetes was diagnosed with acute pyelonephritis complicated with sepsis. Escherichia coli was isolated from both blood and urine cultures. When treated with antibiotics, her condition gradually improved. She suddenly complained of severe right flank pain without fever in the recovery phase. A computed tomography scan revealed right renal artery thrombosis with concomitant renal infarction. Prophylactic anticoagulation therapy was not suggested because of sustained thrombocytopenia and increased risk of bleeding. Flank pain resolved with conservative treatment and perfusion of infarcted kidney improved at the time of discharge. To our knowledge, this is the first case of renal artery thrombosis related to acute pyelonephritis with sepsis-induced DIC.