Treatment of Heparin-Induced Thrombocytopenia (HIT) With Fondaparinux in a Patient With Liver Dysfunction

Type II heparin-induced thrombocytopenia (HIT) is an immune-mediated reaction that usually develops 5-10 days after heparin administration and is mediated by antibodies against a neoantigen of heparin and platelet factor 4 complex. The condition is strongly associated with thrombosis, such as pulmonary embolism. Diagnosis of HIT in patients who underwent liver resection is a challenge compared to other surgical patients. We present the case of a chronic carrier of hepatitis B who presented with a single hepatocellular carcinoma (HCC) in the right lobe. After undergoing right lobectomy without blood transfusion, he was provisioned with low-molecular-weight heparin (LMWH), which was tolerated well. However, after a sudden decrease in platelet count and the onset of tachycardia and shortness of breath, the patient was found to have a partially occluded right pulmonary artery due to pulmonary embolism. After initiating lepirudin, it was discontinued due to unwanted side effects. Thus, fondaparinux was administered, which proved to be effective in increasing the platelet number and resolving the pulmonary embolus. A daily monitoring of anti-factor Xa time was applied using RECALMIX (Amax-Accuclott Heptest, Trinity Biotech, Jamestown, New York, United States). During the first week of fondaparinux administration, initial platelet count values began returning to normal values with resolution of the pulmonary embolus. The patient was discharged in stable condition. This is the first report that shows effective maintenance anticoagulation with fondaparinux of a patient with cirrhosis and post-hepatectomy HIT syndrome complicated by pulmonary embolism. Further studies are required to establish fondaparinux as a new alternative anticoagulant in surgical patients with HIT.