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To the Editor:
Major hemorrhagic complications have been reported in about 5.5% of patients with myeloproliferative disorders, which are more common among patients with essential thrombocytosis. In contrast, the reported risk of bleeding in transbronchial biopsy is 1.9% (1). Major factors predisposing risk factors for postbiopsy bleeding include history of receiving anticoagulation, thrombocytopenia, or uremia. We present the case of fatal hemorrhage after transbronchial biopsy in a patient with essential thrombocytosis with a platelet count of 1,172 k/p.1 and with a background of myelofibrosis.
Case Presentation
A 69-year-old man with myelofibrosis and subsequent transformation into acute myeloid leukemia was admitted with high-grade fever (1038F) and dry cough. His past medical history was significant for primary myelofibrosis (JAK2V617F mutation-negative), which had evolved into acute myeloid leukemia. In addition, he developed thrombocytosis, with platelet counts ranging between 1,000 and 1,200 k/p.1. There was no history of bleeding diathesis.
Physical examination revealed a well-appearing, alert, and oriented gentleman with conjunctival pallor but without any evidence of skin rash to suggest platelet dysfunction. Chest auscultation demonstrated bilateral coarse crackles at both bases, and abdominal examination revealed hepatosplenomegaly. His oxygen saturation was 95% on 2 L of oxygen via nasal cannula.
Laboratory analysis demonstrated low white cell count, at 1.10 k/p.1 (absolute neutrophil count of 110); platelet count of 1,172 k/p.1; international normalized ratio of 1.6; and activated partial thromboplastin time of 46 seconds. The patient's blood urea nitrogen was 18 mg/dl, serum creatinine was 1.17 mg/dl, and liver enzymes were normal. Computed tomography imaging of the chest revealed multiple bilateral solid and sub-solid nodular opacities (Figure 1). The high fever in the context of neutropenia was suggestive of infection, especially fungal disease. Our experience published earlier has demonstrated that the yield of diagnosis in immunocompromised patients is increased when transbronchial biopsy is performed with a bronchoalveolar lavage (2). In addition, transbronchial biopsy would be the only means to make the diagnosis of invasive aspergillosis. The other consideration in this patient was leukemic infiltrates, and hence the appropriate diagnosis would have a significant clinical effect. Therefore, it was decided to proceed with bronchoalveolar lavage and transbronchial biopsy. The patient received 2 units...