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DIC & a negative D-dimer
Disseminated intravascular coagulation and a negative D-dimer test
The doctors from Departments of Internal Medicine and Clinical Chemistry, Albert Schweitzer Hospital reported a case of paraneoplastic Disseminated intravascular coagulation (DIC) with a false-negative D-dimer test.
DIC is characterised by systemic activation of blood coagulation, which occurs under a variety of clinical conditions including sepsis, trauma, malignancy and obstetric disorders. The diagnosis of DIC suffers from the lack of a true gold standard. A scoring system for DIC in critically ill patients has been devised by the International Society of Thrombosis and Haemostasis (ISTH). This scoring system is based on an underlying disorder known to be associated with DIC, a diminished platelet count, a prolonged prothrombin time (PT), a low fibrinogen level, and the presence of a fibrin-related marker. D-dimer assay is used in as a fibrin-related marker. Various D-dimer assays are commercially available. The selection of a D-dimer assay for the routine clinical practice is not only based on its performance, but also on its costs and efficacy.
That case report presented a case in which a negative D-dimer test failed to initially confirm the diagnosis of DIC. A 73-year-old-male was hospitalized for extensive spontaneous hematoma on the left chest. He had a history of transdiaphragmatic resection of the oesophagogastric junction because of a stage T3N0M0 undifferentiated adenocarcinomaresection 12 months ago. Laboratorium examination showed that clotting times (APTT and PT) were prolonged, fibrinogen concentrations was lowered and normal platelets counts. A repeated D-dimer measurement using CARDIAC D-dimer, (Roche, Germany) showed D-dimer value was normal (0,26 and 0,46 mg/L). A CT scan showed multiple enlarged lymph nodes in the mediastinum and retroperitoneal space.
Hiperfibrinogenolysis as a cause of lowered concentration of fibrinogen was confirmed by the presence of increased fibrin/fibrinogen degradation product (FDP). FDP was measured by another D-dimer assay ( VIDAS, bioMérieux, France). The result showed a D-dimer value of 3.02 mg / l (normal <0.5 mg/l). In addition, the activities of antithrombin, plasminogen and α-2-antipasmin were decreased. Based on these results, the diagnosis of DIC was established (score ≥5 based on ISTH scoring system).
Ref: Constantinescu AA, Berendes PB, Levin MD. Disseminated intravascular coagulation and a negative D-dimer test. Neth J Med. 2007;65(10):39-400.