You Make the Call Readers' Response: Management options for a healthy young adult with asymptomatic elevations in D-dimer levels and atypical chest pain.
Here’s how readers responded to a You Make the Call question about management options for a healthy young adult with asymptomatic elevations in D-dimer levels and atypical chest pain.
Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.
I would check her fibrinogen level and for dysfibrinogenemia.
Richard Herrmann, MBBS
I would evaluate for presence of lupus anticoagulant/anticardiolipin antibody.
William Hocking, MD
Her PTT and TT are slightly above the upper limit of normal. She may have slightly low factor V or factor X, but she is not prone to bleeding. I might add an FI assay, as fibrinogen activity can be slightly low if thrombin time is prolonged. Otherwise, she is a healthy lady, so no further testing is needed and no treatment is necessary.
Jae Chang, MD
I am wondering whether the marijuana led to an increase in her D-dimer level. There have been some ongoing studies regarding marijuana causing clot formation.
Ketan Modak, MD
I would like to know if there is a family history of similar symptoms, elevated D-dimers, or thrombotic episodes. I would also like to know of any use of recreational drugs or medication that may be thrombogenic, as well as any occupational exposures.
As per additional investigation, I would recommend thrombophilia screening and abdominopelvic ultrasound with the ovaries in mind, considering the possibility of occult malignancy, as well as other cancer screening tests. I would also recommend a factor XII assay and ruling out secondary activated protein C resistance.
For follow-up, I would recommend serial monitoring of her D-dimer levels.
Theresa Nwagha, MBBS, MPH
I would recommend following up after one month with a repeat D-dimer test.
Amal Hamed, MD
Dubai, United Arab Emirates
I would recommend a venography of the inferior vena cava (IVC) and Iliac veins. Since she is not pregnant, CT venography would be my preference. If these are negative, I would do a follow-up venous ultrasound of the legs within seven days of the initial interrogation. I would also do a COVID-19 screen for asymptomatic disease.
Francis Ssali, MBChB
This may be an early sign of risk of thrombosis. It can be seen in situations where complement is activated due to crosstalk between the complement and coagulation systems. One factor may be exposure of tissue factor by complement mediated tissue damage with subsequent activation of the coagulation system. I would look for reasons for complement activation, examine for thrombosis, and consider prophylactic anticoagulation treatment (low-dose low-molecular-weight heparin).
Torben Plesner, MD
I would test for antiphospholipid syndrome. In our practice, this is one of the most common disorders leading to this finding in young women.
Patricia Cannata Arriola, MD
I would be concerned about occult malignancy, venous thromboembolism (VTE), and severe infection. From the evaluation, it appears that VTE is ruled out, though perhaps repeat testing could be warranted in four to six weeks if all other testing is negative. She does not have signs or symptoms of severe infection, but if background or travel history might suggest something, like parasites, I would test for those. Otherwise, the most concerning thing from my standpoint is an occult malignancy, perhaps carcinoid tumor or other hormone secreting tumor, or perhaps lymphoma given her age. I would want to see a chest, abdomen, and pelvis CT scan with intravenous contrast.
Zainul S. Hasanali MD, PhD
An Italian retrospective study by Lippi et al., found a 26% incidence of VTE in more than 1,600 evaluable cases presenting to the ER. Based on this, and the fact that the patient’s D-dimer value is above 3,000 ng/dL, I would recommend treating this as VTE and following her D-dimer levels sequentially. The patient is very young and I think should be given “the benefit of the doubt,” particularly presenting with sudden onset of chest pain.
A. Osmon, MD
I would recommend clinical and symptomatic follow-up but would not order more tests for now.
Suhu Liu, MD, PhD
Stony Brook, New York
Elevated D-dimer levels have been seen in gastric/esophageal tumors and aortic aneurysms.
Christopher Walsh, MD, PhD
New York, New York