I know that the patient is bleeding, but why? Not always Yin or Yan

Participants

The doctor            The patient               The hematologist

Clinical summary

A-52-year-old woman treated with immunotherapy after a diagnosis of melanoma.  Four months after the first treatment, the patient  started with petechiae and  ecchymosis widely distributed along her skin.

The Lab tests showed a low platelet level and an elevated D-dimer with almost a normal fibrinogen value.

The patient

I’m afraid about my body, I have a lot of red spot on my skin. I need a solution because I feel unwell every day.

The doctor

I’m sure that there is a coagulation problem here,  because the clinical picture and the low level of platelets and the D-dimer elevated.  However, I don´t understand the normal fibrinogen level.  I will prescribe Vitamin K and I will stop heparin.

Do you  have any suggestion? Let’s ask to the hematologist

The hematologist

The clinical picture could be compatible with a disseminated intravascular coagulation. Did you measure the coagulative  or functional fibrinogen? You know, the fibrinogen level can be almost normal because it is also an acute-phase reactant , but probably only a percentage it is useful to work for a proper coagulation function.

Clinical evolution

The functional or coagulative fibrinogen was clearly in a very low level. Fortunately, we will start the therapeutic administration of fibrinogen to improve the clinical situation.

Conclusion

There are in Medicine many details related to the physiopathology or the treatment of every specialty, that could  be an opportunity to start a treatment that could save the life of a person.