Coagulopathies Induced by Disseminated Aspergillosis

Author: 

J Gillies and R Tait
Not Known

Abstract: 

It is not uncommon for the immunocompromised patient with disseminated aspergillosis to develop a coagulopathy. While this will often reflect comorbid disease or sepsis related DIC, occasionally the coagulopathy may result from proteolytic enzymes released from the Aspergillus species. This latter type of coagulopathy is characterised by prolonged thrombin clotting time and, in some cases, may be corrected by protamine sulphate. Vigilance for such coagulation abnormalities in patients susceptible to invasive aspergillosis may facilitate early diagnosis of this condition, allowing institution of appropriate anti-fungal and coagulo-protective measures. The typical patient with disseminated aspergillosis will have an underlying immunocompromising illness and will frequently have received a cocktail of toxic chemotherapy. Concomitant bacterial sepsis and hepatic or renal dysfunction may also be present. Such patients will, therefore, have multiple potential reasons to develop a coagulopathy and bleeding symptoms. Most commonly this will reflect a consumptive coagulopathy (disseminated intravascular coagulation) triggered by bacterial sepsis and tissue necrosis through endotoxin and cytokine release, particularly IL-6 (Levi and ten Cate, 1999; Levi et al., 1999; Tapper and Herwald, 2000). Coexisting liver disease with associated reduced synthesis of coagulation proteins and elimination of activated coagulation factors, may further compound the coagulopathy. Occasionally, patients with disseminated aspergillosis have been noted to suffer a coagulopathy without evidence of disseminated intravascular coagulation (DIC). In some cases, proteolytic enzymes released by the organism appear to have had either a direct or indirect inhibitory effect on coagulation (McClellan et al., 1985; Bouchara et al., 1993). This article will focus on these unusual types of coagulopathy reviewing the evidence to support their existence and patho-aetiology as well as offering a diagnostic approach and potential treatment options.