Anticoagulation-Related Dilemma - A Thrombocytopenic Patient With Numerous Thrombogenic Risk Factors - Case Report

Sep 28, 2026

Anticoagulation is commonly withheld in severe thrombocytopenia, yet clinical decision-making becomes difficult when patients present multiple established venous and arterial thrombogenic risk factors alongside fluctuating platelet counts. Lacking clear guidelines and an easily balanced risk–benefit ratio, this open access case report with discussion provides insight for similar future management challenges. The report emphasizes individualized assessment and continual reassessment when deciding whether to initiate or withhold anticoagulation.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Abstract

Introduction

Anticoagulation and thrombocytopenia risk trade-off

Case details and clinical course

Received 10/05/2025 Review began 11/04/2025 Review ended 11/28/2025 Published 12/04/2025 © Copyright 2025 Johnson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98467 Open Access Case Report Published via Dr. Kiran C. Patel College of Osteopathic Medicine (KPCOM) Anticoagulation-Related Dilemma: AThrombocytopenic Patient With Numerous Thrombogenic Risk Factors Timothy Johnson 1 , Jennifer Trube 1, Juan O. Rodriguez-Padilla 1, Mark Soliman 2, Parker Williams 1, Noah Kosnik 3, Christian Abreu-Ramirez 3 1. Internal Medicine, Lakeland Regional Health, Lakeland, USA 2. Anesthesiology, Lakeland Regional Health, Lakeland, USA 3. Pulmonary Critical Care, Lakeland Regional Health, Lakeland, USA Corresponding author: Timothy Johnson, [tj796@mynsu.nova.edu](tj796@mynsu.nova.edu) Abstract Anticoagulation is typically withheld in cases of severe thrombocytopenia, but clinical decision-making becomes challenging when a patient has multiple established venous and arterial thrombogenic risk factors, along with a fluctuating platelet level. Given the absence of clear guidelines and with an uncertain balance of risks and benefits, this case report and the accompanying discussion may offer useful insights for managing similar situations in the future. A 70‑year‑old male with metastatic adenocarcinoma of the lung presented to the emergency department for evaluation of worsening fatigue and weakness, which had led to a presyncopal episode with a ground-level fall. His cancer had been diagnosed one year prior and treated monthly with radiation, chemo, and immunotherapies. On admission, he was hypotensive, tachycardic, febrile, and markedly pancytopenic. CT imaging suggested pneumonia superimposed on an extensive tumor burden. He was also found to have newonset atrial fibrillation (AF) with a rapid ventricular rate. This was initially rate-controlled with labetalol, but anticoagulation was held due to thrombocytopenia, despite a CHADS₂/VASc score of 2. He was transferred to the ICU for chronic obstructive pulmonary disease exacerbation and septic shock complicated by pancytopenia and neutropenic fever. The patient was treated with broad‑spectrum antibiotics, steroids, filgrastim, vasopressors, intubation, and multiple transfusions (three units of platelets and one unit of packed red blood cells) during the first three days of his five-day admission. Platelet counts ranged between 11 and 61 × 10³/µL despite interventions. On day three, blood cultures grew Pseudomonas; antibiotics were narrowed, and he was successfully extubated to bilevel positive airway pressure. By day four, his atrial fibrillation converted to sinus rhythm for the first time during this admission, and digoxin was initiated due to ongoing hypotension. Subsequently, he developed a complicated pleural effusion that required chest tube placement. Unfortunately, on day five of admission, he exhibited ST‑segment elevations (V2-V6) consistent with anterior myocardial infarction. Due to thrombocytopenia, comorbidities, and goals of care, anticoagulation and reperfusion interventions were deferred. Care transitioned to comfort measures only, and he died 48hours later. This report highlights a unique instance of a common clinical dilemma: determining whether to initiate or withhold anticoagulation in a thrombocytopenic patient with multiple high-risk prothrombotic factors. To our knowledge, no established guidelines specifically address the complex overlap of severe, fluctuating thrombocytopenia and elevated thrombotic risk. This report also underscores the importance of individualized clinical judgment and continual reassessment when making anticoagulation decisions. Categories: Hematology, Cardiology, Oncology Keywords: antic

FAQs

Why was anticoagulation initially withheld in this patient?

Anticoagulation was held because the patient had thrombocytopenia, despite a CHADS₂/VASc score of 2.

What treatments were given during the first days of hospitalization?

He received broad-spectrum antibiotics, steroids, filgrastim, vasopressors, intubation, and multiple transfusions including platelets and packed red blood cells.

What ultimately led to the decision to defer anticoagulation and reperfusion?

The patient developed ST-segment elevations consistent with anterior myocardial infarction, but anticoagulation and reperfusion were deferred due to severe thrombocytopenia, comorbidities, and goals of care.

Sep 28, 2026

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