[Secondary resistance to coumarin derivatives in a patient with a hypercoagulability syndrome]. / Sekundäre Resistenz gegen Cumarinderivate bei einer Patientin mit Hyperkoagulabilitäts-Syndrom.

HISTORY AND CLINICAL FINDINGS: A 23-year-old woman with deep (leg) vein thrombosis was hospitalised because the Quick value had not decreased despite administration of phenprocoumon. Two years previously she had sustained an anterior wall myocardial infarction and a scar on her right kidney had been an incidental sonographic finding. There was bluish, fine reticular discoloration over the toes of both legs. Physical examination was otherwise unremarkable except for obesity. INVESTIGATIONS: The concentration of creatine kinase was raised to 250 U/l and that of lactate dehydrogenase to 300 U/l. The platelet count was decreased to 75/nl. The level of IgG anti-cardiolipin antibodies was raised (204 U/l) and the test for lupus anticoagulant positive. A biopsy of the skin from a toe revealing livedoid vasculitis, primary antiphospholipid syndrome (PAPS) was diagnosed. TREATMENT AND COURSE: Noncompliance, excessive vitamin K ingestion, drug interaction and malabsorption were excluded as cause of the lacking action of phenprocoumon. Despite anti-coagulation with high-dosage low-molecular heparin and inhibition of platelet aggregation with ticlopidine and finally also immunosuppressive treatment with cyclophosphamide, skin necroses developed on the toes and she had recurrent pulmonary embolisms of which she died. CONCLUSION: Standard treatment of PAPS is effective anti-coagulation with coumarin derivatives. Secondary resistance to coumarin is a rare occurrence: its cause remains unknown.

Relationship between maternal and infant iron stores: 1. Full term infants.

Serum ferritin, serum iron and total iron binding capacity were determined in 218 pregnant women at term and in the cord blood of their normal term infants. Both the mean weight (3210 g) and serum ferritin level (geometric mean 81 micrograms/l) of the neonates of iron deficient mothers were significantly lower than those of mothers with "normal" iron stores (weight 3390 g; cord ferritin level 115 micrograms/l). A weakly significant correlation was found between the logarithm of the maternal and neonatal serum ferritin concentration (r = 0.15, p less than 0.05) and the maternal log serum ferritin and the newborn's weight (r = 0.15, p less than 0.05). The weak correlations were supported by the differences between the values of cord samples from babies of iron deficient mothers and those whose mothers had "normal" iron values. Adequate iron supplementation during the early period of pregnancy is suggested.

Penicillin-induced coagulation disorder.

A coagulation disorder was seen after penicillin-G administration (10 million units/day) in uraemic patients and after high-dose penicillin G (40 million units/day) in patients with a normal glomerular filtration-rate (5 patients after cardiac surgery). This disorder was characterised by: prolongation of bleeding-time, appearing immediately after penicillin-G administration and persisting until 4 days after withdrawal of therapy; disturbance of collagen-induced and ristocetin-induced platelet aggregation; increase of antithrombin-III activity; and inhibition of factor-xa activity. The inhibition of factor-xa activity corresponded to that seen after low-dose-heparin prophylaxis. The clinically latent coagulation disorder, when super-imposed upon pre-existing coagulation abnormalities (uraemia, treatment with anti-coagulants) may cause severe bleeding, as observed in 1 patient with acute renal failure on haemodialysis.