Introduction: Chronic Disseminated intravascular Coagulation (DIC) commonly seen in trauma, obstetrical complications, infection, acute leukemia, and mucin-producing solid tumors is described as a systemic sequential activation of the coagulation cascade and fibrinolytic pathways. Simultaneous production of thrombi within the microvasculature result in a consumption coagulopathy and generation of degradation products that interfere with fibrin clot formation and platelet aggregation. Below, we discuss a patient who developed chronic DIC in the setting of newly diagnosed rectal adenocarcinoma.
Methods: A 76-year-old woman with a remote history of breast cancer in remission, and chronic back pain with spinal stimulator presented to the emergency department with aphasia, confusion, 3 weeks of recurrent rectal bleeding, and unintentional weight loss. Upon further review, patient was admitted to hospital four months prior with infectious colitis. CT Abdomen/Pelvis at that time concerning for rectal mass, Hgb 14, Platelets 202. On current admission vitals were stable, labs showed WBC 4.5, Hgb 8.2, Platelets 21, Sodium 124, Potassium 3.3, Total Bilirubin 1.7, ALP 1583, ALT 19, AST 94. Hemolytic workup revealed: LDH 4917, PT 16.5, INR 1.4, Fibrinogen 363, D-dimer >20, schistocytes observed on peripheral smear. Hematology was consulted and diagnosed chronic DIC presumably from rectal cancer. Declining mental status was concerning for microthrombi events to the brain, however CT head only showed chronic ischemic changes, MRI not obtained due to spinal stimulator. Flexible sigmoidoscopy with biopsy of fungating, bleeding rectal mass revealed poorly differentiated rectal adenocarcinoma with necrosis. Family opted for hospice and died one day after discharge. Discussion: In chronic DIC, sporadic exposure and clearing of small amounts of tissue factors by the liver precludes severe complications. Clotting times and thrombocytopenia may be normal or mild, however, fibrinogen can be elevated and consequently thrombosis is the predominate feature. This case has two key learning features, one, the differential of chronic DIC should be added to any patient with hemolytic anemia and known or presumed malignancy, and two, chronic DIC is a distinct etiology from acute DIC with fibrinogen elevation and likely micro thrombotic processes on presentation. DIC should be ruled out in patients presenting with neurologic symptoms with known or presumed malignancy as treatment modalities are distinct from other etiologies.
Disclosures: Rachael Weigle indicated no relevant financial relationships. Jayme Cannon indicated no relevant financial relationships. Golnosh Sharafsaleh indicated no relevant financial relationships. Gerald Mank indicated no relevant financial relationships.