Nadia Rafique MBChB
Foundation year 1 trainee
Department of Surgery
Basildon and Thurrock University Hospital
Basildon Essex United Kingdom
Somayyeh Mossadegh MBChB
Foundation year 1 trainee
Department of Surgery
Basildon and Thurrock University Hospital
Basildon Essex United Kingdom
Senthil Kumar MS, FRCS (Ed)
Specialist Registrar in Surgery
Department of Surgery
Basildon and Thurrock University Hospital
Basildon Essex United Kingdom
NJ Menon MS, FRCS (Ed)
Consultant Vascular Surgeon
Department of Surgery
Basildon and Thurrock University Hospital
Basildon Essex United Kingdom
Citation: N. Rafique, S. Mossadegh, S. Kumar & N. Menon : Abdominal aortic aneurysm: A Surgical Cause For Isolated Thrombocytopenia And Easy Bruising . The Internet Journal of Surgery. 2008 Volume 16 Number 1
Keywords: Thrombocytopenia | Easy bruising | Aortic aneurysm
Abstract
Most causes of thrombocytopenia are non-surgical and are managed medically. However, surgical causes should not be overlooked. We report an eighty-year-old male patient who presented with easy bruising because of thrombocytopenia. Evaluation showed a large infra-renal abdominal aortic aneurysm with associated iliac aneurysm. Surgical repair of the aneurysms resolved the thrombocytopenia. Abdominal aortic aneurysm should be considered in evaluating elderly patients with easy bruising and/or thrombocytopenia.
Introduction
Thrombocytopenia may be caused by reduced production, increased destruction or sequestration of platelets. With exceptions such as hypersplenism and idiopathic thrombocytopenic purpura, which may benefit from surgery, the causes are usually managed medically. We report the case of a patient who was thrombocytopenic, presented initially with easy bruising and was found to have a large abdominal aortic aneurysm, the surgical treatment of which cured the thrombocytopenia.
Case report
An 80-year-old Caucasian gentleman was referred to the medical assessment unit by his general practitioner for a low platelet count (77x10 9 /L) and easy bruising. The patient had a history of easy bruising for one month, but was otherwise asymptomatic. On examination, he had no hepatosplenomegaly. However, an incidental finding of a large abdominal aortic aneurysm (AAA) was noted. An urgent CT scan confirmed an infra-renal AAA of 10cm diameter, a right common iliac aneurysm of 7cm and a left common iliac aneurysm of 5cm diameter. There was no other cause for the thrombocytopenia. The prothrombin time and activated partial thromboplastin time were normal.
The patient underwent an open endoaneurysmorraphy of his aortic and iliac aneurysms using a dacron tube graft. A total of 8 units of packed red cells, 4 units of platelets and 2 units fresh frozen plasma were transfused perioperatively. His postoperative course was uneventful. Interestingly, his platelet count showed a steady increase postoperatively starting from the third postoperative day and reaching normal levels by the seventh day. The increase was sustained when he was discharged on the 14 th day (fig. 1). His pre-operative platelet count was 88x10 9 /L, while the platelet count at discharge was 303x10 9 /L. The platelet count remained normal at follow up 2 months later.
Discussion
The management of abdominal aortic aneurysms may be complicated by coagulopathy. This is often seen intra-operatively or postoperatively due a multitude of factors including blood loss, multiple transfusions and the effects of aortic cross clamping. Pre-operative low-grade disseminated intravascular coagulation (DIC) has been reported in association with AAA, but is uncommon 1,2,3,4 . Patients with aortic aneurysms have been observed to have a slightly lower platelet count than the general population 5 . The patient presented above had pre-operative isolated thrombocytopenia which was corrected by treatment of his aneurysm. While the patient received two units of platelet transfusion intra-operatively, the continued and sustained rise in the platelet count two weeks after transfusion cannot be explained by the transfused platelets as the lifespan for platelets is only 5-10 days 6 . Mukaiyama et al. have demonstrated increased platelet activity in aneurysms by using Indium-111 labelling technique 7 . We propose that the symptomatic thrombocytopenia was due to consumption at the site of the aneurysm. In elderly patients who present with easy bruising and thrombocytopenia, the possibility of an abdominal aortic aneurysm should be considered in the diagnostic work up.
Address for correspondence
Dr Senthil Kumar
Flat 83, City view, Centreway
Axonplace
Ilford
Essex, UK
IG1 1NH
E mail:
[sanskrity@hotmail.com]
Ph: 00-44-07737495294
References
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3. Rowlands TE, Norfolk D, Homer-Vanniasinkam S. Chronic disseminated intravascular coagulopathy cured by abdominal aortic aneurysm repair Cardiovascular Surgery 2000; 8 (4): 292-294. (s)
4. Nikapota ADB, Stern SCM. Bruising in a man with aortic aneurysms. J R Soc Med 2002; 95: 556-557. (s)
5. Milne AA, Adam DJ, Murphy WG and Ruckley CV. Effects of asymptomatic abdominal aortic aneurysms on the coagulation system, platelet count and platelet activation. European Journal of Vascular and Endovascular Surgery 1999; 17: 434-437. (s)
6. Najean Y, Ardaillou N, Dresch C. Platelet lifespan. Annual Review of Medicine 1969; Vol. 20: 47. (s)
7. Mukaiyama H, Shionoya S, Ikezawa T, Kamiya T, Hamaguchi M, Saito H. Abdominal aortic aneurysm complicated with chronic disseminated intravascular coagulopathy: a case of surgical treatment. Journal of Vascular Surgery 1987; 6: 600-604. (s)
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