Physician Henry Ford Hospital Detroit, Michigan, United States
Background: Various medications and infectious organisms have been implicated in the formation of antiphospholipid antibodies. Intra-operative bovine thrombin use can lead to cross-reactive antibody production and subsequent thrombophilia.
Aims: We present the case of a 77-year-old female who presented with acute right lower extremity deep venous thrombosis (DVT) and pulmonary embolism (PE) one week after undergoing anterior cervical discectomy and fusion. She had no prior history of venous thromboembolism (VTE) and no history of recurrent miscarriages. Family history was only notable for DVT in her sister at the age of 90. Platelet count at the time of surgery and DVT/ PE diagnosis was normal. The thrombosis was considered provoked in the setting of recent surgery and immobility and she was planned to be treated with apixaban 5 mg BID for three months.
Methods: Further review of her laboratory investigations revealed prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) in her hospital admission prior to the initiation of heparin. Anti-cardiolipin IgM and anti-beta 2 -glycoprotein IgM were elevated, 66.2 MPL and 87 SAU, respectively. She was maintained on apixaban 5 mg BID until repeat testing twelve weeks later showed persistently and increasingly elevated anticardiolipin IgM (93.5 MPL) and anti-beta 2-glycoprotein IgM (107 SAU).
Results: Therapeutic anticoagulation was changed to warfarin and titers normalized over the next six months. Lupus anticoagulant was negative after anticoagulation discontinuation.
Upon follow-up six months later, she was diagnosed with rheumatoid arthritis and shortly thereafter COVID-19. Repeat lab studies showed that she had positive lupus anticoagulant and elevated titers of beta 2 glycoprotein IgG and IgM in the setting of active COVID-19 and was placed on anticoagulation again.
Conclusion(s): This case highlights the hypercoagulability that can be associated with bovine thrombin use and the importance of reviewing VTE history in the context of a patient’s evolving medical history.
