ŠTA SMO NAUČILI IZ NEADEKVATNOG TESTIRANJA D-DIMERA – PRIKAZ SLUČAJA
Sažetak
Uvod: Od proglašenja KOVID-19 pandemije, testiranje D-dimera često se koristi u nestandardnim i često neopravdanim indikacijama. Ovo je dovelo do pogrešnih dijagnoza, prekomernog sprovođenja dijagnostičkih procedura i nepotrebnih troškova.
Prikaz slučaja: Bolesnica, stara 50 godina, javila se u službu urgentne medicine sa tegobama u vidu bola u grudima, kratkog daha, zamaranja i bola u levoj nozi. U učinjenim analizama uočen je povišen D-dimer (4,73 mg/l (N:<0,5)) zbog čega su isključeni tromboza dubokih vena, plućna tromboembolija, kao i KOVID-19. Nakon toga u terapiju je uveden rivaroksaban u dozi od 10 mg/dan. Nakon sedam dana, D-dimer je i dalje rastao (17,52 mg/l), pa je umesto rivaroksabana uveden nisko-molekularni heparin. Nakon još pet dana, D-dimer je i dalje rastao (27,26 mg/l), a u nalazu kompletne krvne slike (KKS) je uočena trombocitopenija (54 x 109/l). Kako je 4T skor za heparinom indukovanu trombocitopeniju bio 5, urađena su anti-heparin/PF4 antitela koja su bila pozitivna (4+). U terapiju je uveden fondaparinuks-natrijum, a pacijentkinja je upućena hematologu. Na hematološkoj kontroli je uočeno krvarenje po koži i sluznici gingive. U laboratorijskim analizama uočeni su pancitopenija (hemoglobin = 101 g/l; leukociti (WBC) = 1,7 x 109/l; trombociti = 29 x 109/l) i potrošna koagulopatija (INR = 1,7; aPTT = 27,1 s; fibrinogen = 0,8 g/l; D-dimer = 30,9 mg/l). Učinjena je aspiracija koštane srži nakon čega je postavljena dijagnoza akutne monoblastne leukemije, 47, XX, + 12 [4] / 46, XX [16], FLT3-ITD, NPM1 – divlji tip.
Zaključak: D-dimer je moćan dijagnostički test ukoliko se koristi prema indikacijama. Nikada se ne sme sagledavati kao izolovan rezultat, a uvođenje terapije samo na osnovu povišenih vrednosti D-dimera se ne savetuje.
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