Fibrinogen Levels and Bleeding Risk in Patients Undergoing Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism.

OBJECTIVES: We sought to test the hypothesis that patients undergoing ultrasound-assisted catheter-directed thrombolysis (USAT) with standard alteplase and heparin dosing would not develop significant depletion of systemic fibrinogen, which may account for the lower risk of bleeding seen in contemporary trials. We also sought to compare the relative outcomes of individuals with submassive pulmonary embolism (PE) undergoing USAT and anticoagulation alone. METHODS: Utilizing a single-center prospective registry, we identified 102 consecutive adult patients with submassive PE who were considered for USAT based on a standardized treatment algorithm between November 2016 and May 2019. Patients not receiving USAT therapy were treated with anticoagulation alone. RESULTS: Baseline characteristics were generally similar between groups (n = 51 in each group). Major bleeding rates were not significantly different between groups (2.0% vs 5.9% in USAT vs control, respectively; P=.62). Notably, no USAT patient experienced clinically significant hypofibrinogenemia (mean trough fibrinogen, 369.8 ± 127.1 mg/dL; minimum, 187 mg/dL). The mean trough fibrinogen of patients experiencing any bleeding event (major or minor) was 306.6 mg/dL (SE, 23.9 mg/dL) vs 380.3 mg/dL (SE, 20.4 mg/dL) in those without a bleeding event (P=.02). CONCLUSIONS: In this cohort analysis of patients undergoing USAT, there was no evidence for clinically significant depletion of fibrinogen or intracranial hemorrhage. Although our data suggest an association between lower fibrinogen levels and bleeding events, our results are not clear enough to suggest a clinically useful fibrinogen cut-off value. Further study is needed to determine the utility of routine fibrinogen monitoring in this population.

Novel Findings in HIV, Immune Reconstitution Disease and Strongyloides stercoralis Infection.

We report the successful treatment of an HIV-infected patient with progressive strongyloidiasis as a component of immune reconstitution disease and a review of the literature on this topic. In our experience, pre- and post-antiretroviral therapy intestinal biopsies support a novel mechanism of immune reconstitution disease to Strongyloides stercoralis. We conclude that extended, dual antihelminthic therapy and temporary discontinuation of antiretroviral therapy may be effective in similar patients.