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CC BY 4.0 · Indian J Med Paediatr Oncol 2024; 45(01): 087-091
DOI: 10.1055/s-0043-1769789
Case Report with Review of Literature

Bleeding Diathesis Secondary to a Heparin-Like Anticoagulant in a Patient with Multiple Myeloma—A Case Report and Review of Literature

Nihar Desai
1   Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Seema Biswas 
1   Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Dinesh Chandra
1   Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Ruchi Gupta 
1   Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Anshul Gupta
1   Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Rajesh Kashyap
1   Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
› Author Affiliations Funding None.
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Abstract

Multiple myeloma (MM) is a clonal plasma cell disorder that commonly presents with anemia, renal failure, hypercalcemia, and lytic bone lesions. MM is also frequently associated with thrombotic complications; however, it may rarely present with bleeding diathesis. We report a case of a 42-year-old gentleman with relapsed immunoglobulin G lambda MM who presented with epistaxis, gingival bleeding, and oozing at the venepuncture site. Routine tests of coagulation revealed a prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT), and thrombin time. The PT and aPTT failed to correct with pooled normal plasma and the patient was thus diagnosed to have an acquired heparin-like anticoagulant (HLAC). The source of this HLAC has long been debated, but recent data have demonstrated that this HLAC may be the paraproteins produced by the malignant plasma cells. The patient was treated with intravenous protamine sulfate, repeated cycles of plasma exchange, and a daratumumab-based quadruplet regimen but eventually succumbed to an intracranial hemorrhage. HLAC is a rare but potentially fatal complication of MM that must be considered when patients with MM present with bleeding diathesis.

Keywords

bleeding - multiple myeloma - daratumumab - heparin

Declaration of Patient Consent

Yes.




Publication History

Article published online:
18 September 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Saif MW, Allegra CJ, Greenberg B. Bleeding diathesis in multiple myeloma. J Hematother Stem Cell Res 2001; 10 (05) 657-660
    CrossrefPubMedGoogle Scholar
  • 2 Tefferi A, Owen BA, Nichols WL, Witzig TE, Owen WG. Isolation of a heparin-like anticoagulant from the plasma of a patient with metastatic bladder carcinoma. Blood 1989; 74 (01) 252-254
    CrossrefPubMedGoogle Scholar
  • 3 Rodgers GM, Corash L. Acquired heparinlike anticoagulant in a patient with metastatic breast carcinoma. West J Med 1985; 143 (05) 672-675
    PubMedGoogle Scholar
  • 4 de Prost D, Katlama C, Pialoux G, Karsenty-Mathonnet F, Wolff M. Heparin-like anticoagulant associated with AIDS. Thromb Haemost 1987; 57 (02) 239-239
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Perkins HA, MacKenzie MR, Fudenberg HH. Hemostatic defects in dysproteinemias. Blood 1970; 35 (05) 695-707
    CrossrefPubMedGoogle Scholar
  • 6 Chapman GS, George CB, Danley DL. Heparin-like anticoagulant associated with plasma cell myeloma. Am J Clin Pathol 1985; 83 (06) 764-766
    CrossrefPubMedGoogle Scholar
  • 7 Rahman S, Veeraballi S, Chan KH, Shaaban HS. Bleeding diathesis in multiple myeloma: a rare presentation of a dreadful emergency with management nightmare. Cureus 2021; 13 (03) e13990
    PubMedGoogle Scholar
  • 8 Saadalla A, Seheult J, Ladwig P. et al. Sialic acid-bearing paraproteins are implicated in heparin-like coagulopathy in patients with myeloma. Blood 2020; 136 (17) 1988-1992
    CrossrefPubMedGoogle Scholar
  • 9 Khoory MS, Nesheim ME, Bowie EJ, Mann KG. Circulating heparan sulfate proteoglycan anticoagulant from a patient with a plasma cell disorder. J Clin Invest 1980; 65 (03) 666-674
    CrossrefPubMedGoogle Scholar
  • 10 Torjemane L, Guermazi S, Ladeb S. et al. Heparin-like anticoagulant associated with multiple myeloma and neutralized with protamine sulfate. Blood Coagul Fibrinolysis 2007; 18 (03) 279-281
    CrossrefPubMedGoogle Scholar
  • 11 Mumford AD, O'Donnell J, Gillmore JD, Manning RA, Hawkins PN, Laffan M. Bleeding symptoms and coagulation abnormalities in 337 patients with AL-amyloidosis. Br J Haematol 2000; 110 (02) 454-460
    CrossrefPubMedGoogle Scholar
  • 12 Tefferi A, Nichols WL, Bowie EJ. Circulating heparin-like anticoagulants: report of five consecutive cases and a review. Am J Med 1990; 88 (02) 184-188
    CrossrefPubMedGoogle Scholar
  • 13 Shen H, Wu C, Chen L, Zhang R. Acquired heparin-like anticoagulation process in a patient with multiple myeloma: a case report and literature review. Transl Cancer Res 2020; 9 (11) 7366-7371 https://tcr.amegroups.com/article/view/45909 cited 2022Mar27 [Internet]
    CrossrefPubMedGoogle Scholar
  • 14 Kaufman PA, Gockerman JP, Greenberg CS. Production of a novel anticoagulant by neoplastic plasma cells: report of a case and review of the literature. Am J Med 1989; 86 (05) 612-616
    CrossrefPubMedGoogle Scholar
  • 15 Palmer RN, Rick ME, Rick PD, Zeller JA, Gralnick HR. Circulating heparan sulfate anticoagulant in a patient with a fatal bleeding disorder. N Engl J Med 1984; 310 (26) 1696-1699
    CrossrefPubMedGoogle Scholar
  • 16 Llamas P, Outeiriño J, Espinoza J, Santos AB, Román A, Tomás JF. Report of three cases of circulating heparin-like anticoagulants. Am J Hematol 2001; 67 (04) 256-258
    CrossrefPubMedGoogle Scholar
  • 17 Goddard IR, Stewart WK, Hodson BA, Dawes J. Plasma exchange as a treatment for endogenous glycosaminoglycan anticoagulant induced haemorrhage in a patient with myeloma kidney. Nephron J 1990; 56 (01) 94-96
    CrossrefPubMedGoogle Scholar
  • 18 Martínez-Martínez I, González-Porras JR, Cebeira MJ. et al. Identification of a new potential mechanism responsible for severe bleeding in myeloma: immunoglobulins bind the heparin binding domain of antithrombin activating this endogenous anticoagulant. Haematologica 2016; 101 (10) e423-e426
    CrossrefPubMedGoogle Scholar
  • 19 Willner CA, Chisti MM. Treatment of bleeding diathesis associated with a heparin-like anticoagulant in plasma cell neoplasia using protamine. Case Rep Hematol 2018; 2018: 4342301
    PubMedGoogle Scholar