Download Warfarin Use in Thrombocytopenic Young Adult Male with Atrial

Warfarin Use in Thrombocytopenic Young Adult Male with Atrial Fibrillation
Levina Tri Ratana1, Hizkia1, Michael Jonathan1, Arif Ridha2, Arinta Setyasari3, Prihati
Pujowaskito4
1
Cardiology Intern at Dustira Hospital, 2General Practitioner at Dustira Hospital,
3
Cardiologist at Dustira Hospital, 4Head of Cardiology Department at Dustira Hospital
Introduction
Prevalence of atrial fibrillation in adult less than 40 years is about 0.1% per year. Fever
and thrombocytopenia in rheumatic heart disease are frequently misdiagnosed with viral
illness, restraining patient from vitamin K antagonist use which might be life saving,
particularly in atrial fibrillation with structural heart disease.
Case
A 16 year-old male came to the ER with dyspnea on exertion since 3 days prior to
admission. Paroxysmal nocturnal dyspnea and edema of extremities were also
complained. There was no previous history of similar complain. There was a history of
untreated pharyngitis followed by shortness of breath on childhood. On physical
examination, his temperature was 38.9, jugular venous pressure was 5+4 cmH2O,
crackles were present on both lung and pretibial edema. Hyperemia and tenderness was
found on elbows and knees. ECG showed atrial fibrillation with rapid ventricular
response. Laboratory examination revealed thrombocytopenia (95.000/mm3) and elevated
erythrocyte sedimentation rate. Transthoracal echocardiography displayed severe mitral
stenosis with mild mitral regurgitation. The patient was diagnosed with decompensated
heart failure stage C functional class 3, severe mitral stenosis, mild tricuspid
regurgitation, and atrial fibrillation rapid ventricular response. Thrombocytopenia in this
patient was mistakenly diagnosed with dengue fever and temporarily restraint the patient
from taking warfarin. On the third day, the laboratory test was repeated,
thrombocytopenia persisted (97.000/mm3) and IgM and IgG anti-dengue test was
negative. Thus, thrombocytopenia was linked to rheumatic heart disease and warfarin
was administered. The patient was treated with erythromycin 4x500mg, digoxin 1x0.25
mg, and furosemide 1x40 mg iv. After treatment, rate control was achieved and the
symptom improved. The patient was then referred to a higher cardiac care center for
valve surgery.
Discussion
Warfarin use in atrial fibrillation is vital in preventing systemic embolization. In patients
with valvular disease, vitamin K antagonist should be administered without counting
CHA2DS2VASc Score. Thrombocytopenia occurs frequently in rheumatic heart disease
and does not essentially indicate viral infection. Thrombocytopenia >50.000/mm3 should
not delay the administration of vitamin K antagonist.
Conclusion
Thrombocytopenia and fever occurs concurrently in rheumatic heart disease patient. Nonsignificant thrombocytopenia should not delay the administration of vitamin K antagonist
in AF patients.