Question of the week # 286

286) A 55 year old woman with history of diabetes mellitus and hypertension is admitted with chest pain. Chest pain started about 30 minutes ago but now resolved after she received sublingual nitroglycerin. An electrocardiogram obtained by EMS showed ST segment depressions but a repeat electrocardiogram in the Emergency room is normal. She is placed on Aspirin, low molecular weight heparin, atorvastatin and metoprolol. She denies any easy bruising, nose bleeding or any other gross bleeding. She denies smoking , alcohol or drug abuse She has not been admitted to any hospital and has never received anticoagulants in the past. Physical examination  is benign . Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 8k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Three sets of cardiac enzymes are negative. Cardiology team held aspirin and low molecular weight heparin immediately. A peripheral blood smear is shown below:


Which of the following is the most appropriate next step in management?

A) Platelet transfusion

B) Heparin induced platelet antibodies

C) Start Lepirudin

D) Send CBC in a citrate tube

E) IV Gamma Globulin

8 Responses

  1. I will go for CC.

  2. ANS:D
    The condition is Pseudothrombocytopenia
    There is a condition called pseudothrombocytopenia, spuriously low platelet count due to a laboratory artefact, in which the platelets clump together. In such instances the instrument does not count these clumps of platelets and gives the platelet count as factitiously low. This can be confirmed by examining a peripheral blood smear in which many clumps of platelets will be seen suggesting that the platelet count is normal. Sometimes, changing the anticoagulant in which the blood is collected from EDTA to citrate or heparin may solve the problem but rarely, platelets may clump on being exposed to any anticoagulant. If a platelet count is still required in such cases, a manual platelet count is done using finger-prick blood and directly collecting the blood into the diluting fluid.

    Read more

    • the patient denies any easy bruising, nose bleeding or any other gross bleeding. No history of hospitalization….

  3. d


  5. ddd

  6. DD

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