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C0348: Acute Deep Venous Thrombosis Associated with Acute Brucellosis: A Case Report
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POSTERS / Thrombosis Research 133S3 (2014) S35–S123
yellow color of the skin, mild purpura and pains all over the body. Physical and routine laboratory examination was performed. Additional tests such as peripheral blood smear, Coombs test and coagulation screening tests (TT, PTT and TT) were also performed. Results: The physical examination revealed high hart rate, fever and neurological symptoms (confusion and paresis). Laboratory tests showed anemia, thrombocytopenia and impaired renal function. The complete blood count (CBC) showed reduced number of red blood cells (1.8×1012 /L with hemoglobin level of 50 g/L) and thrombocytopenia (60×109 /L). Hemolytic anemia was confirmed with the fallowing findings: indirect bilirubin – 21.5 mmol/L (normal range: 5–13 mmol/L), high serum lactate dehydrogenase (LDH) – 1200 U/L (the normal range: 213–423 U/L), slide review of the blood smear indicated the presence of spherocytes, schistocytes and increased number of reticulocytes, direct Coombs test was negative. The coagulation tests were within the reference interval, as well as the level of von Willebrand factor. Renal dysfunction was presented with elevated serum creatinine of 156 mmol/L (normal range: 44– 116 mmol/L) and the presence of red and white blood cells, proteins and glucose in the urine. The patient benefited from the plasma exchange treatment with fresh frozen plasma and cryosupernatant plasma. Conclusions: The early onset with plasmapheresis although the diagnosis of TTP is only a presumptive one can be lifesaving therapy in cases with microangiopathic hemolytic anemia in the absence of other obvious causes. C0128 UNUSUAL PRESENTATION OF A LEFT ATRIAL THROMBUS MIMICKING A CARDIAC MYXOMA 1 M. Padilla Perez ´ , F. Almagro Torres1 , M. Sanchez de Castro1 , C. Lozano Cabezas1 , E. Vazquez Ruiz de Castroviejo1 , D. Salas Bravo1 , J. Torres Llergo1 , J. Carlos Fernandez Guerrero1 . 1 Spain
Background: In nonvalvular atrial fibrillation (AF), left atrial thrombi almost exclusively arise in the atrial appendage. However, some unusual presentations have been described, attached to the interatrial septum by a stalk, mimicking a cardiac myxoma. Surgical resection is recommended in myxomas, while oral anticoagulation is the first line therapeutic option for LA thombus. Methods: We present the case of a 76 year-old man with hypertension, referred for cardiovascular examination because of a first known episode of AF. There were no murmurs on cardiac auscultation. Transthoracic echocardiography (TTE) showed a markedly dilated left atrium (49 mm) and normal left ventricular systolic function. The left-sided cardiac valves moved appropriately. A mobile mass was identified, adjacent to the interatrial septum in the left atrium (LA) (Figures 1 and 2). On transesophageal echocardiography (TEE), a 15×14 mm mass was seen in the LA, and attachment to the interatrial septum by a stalk was confirmed. It had an irregular surface and heterogeneous appearance with a central hypoechoic area. No mass was seen in the LA appendage. In view of these observations, it could be either a myxoma or a thrombus. Oral anticoagulant therapy with warfarin was prescribed and a second echocardiographic examination after 4 weeks of treatment was performed, showing the absence of any intracardiac mass (Figures 3 and 4) confirming that it was indeed a thrombus. The patient had no thromboembolic events during that period of time. Results: Figures of the transthoracic and transesophageal echocardiogram will be displayed in the poster. Conclusions: Echocardiographic distinction between a thrombus and a myxoma in the LA is not always straightforward, and the clinical context must be taken into account. LA thrombi, which appear more frequently than cardiac myxomas, typically originate in the LA appendage, and generally occur in patients with AF, enlarged atrial chamber, prosthetic mitral valve or mitral stenosis.
However, some atypical LA thrombi have been described, attached by a stalk to the left atrial septal pouch in the fossa ovalis, and can be wrongly diagnosed as myxomas, leading to an unnecessary surgical resection. The key messages are: 1. In a LA mass with stalk, echocardiographic differential diagnosis between thrombus and myxoma may be difficult. 2. TEE should be performed for better definition of the mass characteristics, such as the shape, site of attachment, margins, and presence or absence of thrombus in the LA appendage 3. When the differential diagnosis remains difficult and thrombus is a possibility, such as in AF, a trial of anticoagulation may be advised before sending the patient to cardiac surgery. C0335 MEDIAN ARCUATE LIGEMENT SYNDROME AND THROMBOPHILIA: CASE REPORT D. Glavas1 , K. Novak1 . 1 Uni Hospital Split, Soltanska 1, Split, Croatia Background: Median arcuate ligament syndrome-MALS, also known as celiac artery compression syndrome or Dunbar syndrome, is characterized by nausea, vomiting and recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. Usually, in 1 /4 of healthy people, ligament pass under celiac artery, causing artery compression. The consequence could be decreasing in blood flow throughout abdominal organs and mesenteric artery. Methods: The diagnosis is often one of exclusion, given the non-specific symptoms which overlap with other forms of chronic intestinal ischemia, and include angiography and Doppler examination tests. Results: Our patient (53 year old female) was admitted to the hospital because of swelling of the left leg. After admission, ultrasound revealed thrombus of lower part of femoral vein with expansion to the popliteal and fibular vein. Besides, there was found an older thrombus in right common iliac vein. The initial treatment included enoxaparin and warfarin. Soon after admission, patient reported pain in the lower part of abdomen with headache, perspiration, and increasing in blood pressure. The abdominal ultrasound examination was orderly. Abdominal MSCT scan with angiography was also performed because of suspicion on embolism and thrombosis. The scan had shown that common hepatic artery and artery three came out of the aorta (instead of celiac truncus), and, after that, was branching on the lienal and left gastric artery as anatomical variation. Other tests included positive D-dimer test (2.52 mg/L; normal range 0–0.5 mg/L), and positive thrombophilia test (patient was heterozygote on factor V-Leiden). The treatment was continued with the same medication (enoxaparin and warfarin). The surgeon did not suggest the surgical intervention, because this was the first disease attack. After the hospital treatment, the patient was clinically better, and she was discharged with warfarin in therapeutic range (the value of INR was 2.5–3). Six month after the discharge, on control examination, the clinical profile was excellent. Conclusions: In everyday clinical practice, we should think that MALS could be associated with thrombophilia and thrombosis. C0348 ACUTE DEEP VENOUS THROMBOSIS ASSOCIATED WITH ACUTE BRUCELLOSIS: A CASE REPORT S. Salihi1 , M. Kalender1 , M. Tasar1 . 1 Nide State Hospital. Nide, Turkey Background: Brucellosis is a zoonotic disease common in developing countries. Vascular complications, including arterial and venous, associated with Brucella infection have rarely been reported. A case of deep venous thrombosis (DVT) developing after a diagnosis of acute brucellosis in a young milkman is presented.
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
Case presentation: A 26-year-old man presented with pain in the right leg. The patient’s medical history included a diagnosis of brucellosis in our hospital where he had presented with complaints of weakness and fever. Peripheral venous Doppler ultrasound showed DVT and patient was treated with anticoagulants. The patient was discharged with warfarin therapy and anti-brucellosis treatment. Conclusions: Although rare, some infectious agents may cause vascular pathologies. Patients presenting with symptoms of DVT or similar vascular pathologies should be assessed for infectious agents particularly in those coming from Brucella-endemic areas. C0466 TOTAL ABDOMINAL HYSTERECTOMY AND POSTOPERATIVE BLEEDING DIATHESIS: A CASE REPORT T. Vucemilo1 , M. Puljiz1 , I. Alvir1 , I. Mamic1 , M. Skoko1 . 1 University Hospital Sisters of Charity University Hospital for Tumors. Transfusion, Zagreb, Croatia Background: Uterine myoma is the most common benign genital tumor among women of reproductive age. Total abdominal hysterectomy (TAH) is the most common type of hysterectomy. The average blood loss during TAH is approximately 300ml. Surgical blood loss that requires a blood transfusion is usually defined as intraoperative hemorrhage. Intraoperative hemorrhage has been reported in 1% to 2% of hysterectomy studies. Methods: We present a case of TAH complicated with bleeding diathesis and blood loss more than 2500 ml. A 42-year-old woman 3-para had a five year history uterine myoma. Her past medical history was free of any medical problems. She was found to be anemic with Hg of 6.3 g/dl. Four days before surgery she had 600 ml packed red blood cells transfused. Before surgery her Hg was 10 g/dl. PLT 233x/l Coagulation parameters were normal: PT 12.6 s, APTT 29 s, TT 15 s, Fibrinogen 4.2 g/l. She underwent open myomectomy via a low transverse incision when the uterus found to be enlarged to the size of a 12-week pregnancy. The estimated blood loss was 300 ml and there were no complications. The patient was hemodinamically stable until the end of surgery. Three to four hours postoperatively she became dyspneic. She was hypotensive and tachycardic. Her Hg dropped to 5.4 g/l. She had remarkably prolonged coagulation parameters PT 23.5 s, INR 2.0, APTT 69 s, TT 27 s, Fibrinogen 1.0 g/l, PLT 60. Ultrasonography revealed free fluid filling the pelvis in lower abdomen. A diagnosis of intrabdominal bleeding was set and she underwent immediate laparotomy with appropriate resuscitation with i.v. fluid, blood, FFP, cryoprecipitate and ciclokapron. Results: At laparotomy an estimated 2000 ml of blood was found in the peritoneal cavity, and there was no evidence of active arterial bleeding. The total estimated blood loss during surgery was 2500 ml and patient received 2100 ml packed red blood cells, two unit FFP, two pools platelets, two dose cryoprecipitate 850 AHF, ciclokapron 1500 mg. Under supplementation of blood components subsequent laboratory finding improved with stabile vital sign and a satisfactory recovery. Conclusions: Bleeding diathesis can be caused by many solid tumors but TAH induced bleeding diathesis is rare. Recently published data demonstrates that women presented with menorrhagia frequently report an additional history of bleeding after surgery. We need additional efforts to develop hematological screening tools within women presenting with menorrhagia.
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C0536 DIGITAL MICROTHROMBOSIS IN SYSTEMIC SCLEROSIS: THINK ABOUT ESSENTIAL THROMBOCYTHEMIA F. Ajili1 , A. Tliba1 , N. Boussetta1 , H. Ghedira1 , I. Gharsallah1 , L. Metoui1 , B. Louzir1 , N. ben Abdelhafidh1 , S. Othmani1 . 1 Military Hospital in Tunis. Internal Medicine. Tunis, Tunisia Background: Digital microthrombosis are a well-known problem in patients with systemic sclerosis. Essential thrombocytosis is another cause of this disease. It causes digital ulcers which increase impairment of hand function. Methods: We report clinical charts of a female 68 year old patient with a rare association of essential thrombocythemia and systemic sclerosis. Results: A 68 year old women presented with a 2 week history of pain and bilateral bluish discoloration of the finger tips and toes, epigastric pain, post prandial vomiting, heartburn and dysphagia. Physical examination showed proximal skin sclerosis, thin skin, less hair, bilateral and symmetrical sclerodactily and pulp ulcers of ten fingers and the big toes. Abnormality in complementary investigations were platelet count of 634000 elements/mm3 in blood test, interstitel syndrome in chest radiography and resorption of phalangeal tufts of several fingers in hand radiographs. Then the diagnosis of systemic sclerosis was confirmed. The clinical outcome, after treatment with calcium channel blockers and colchicine, was marked by the extent of digital ulcers. On the other hand, the thrombocytosis was compounded. A bone marrow biopsy was done and concluded at a megakaryocytic lineage hyperplasia, and presence of JAk 2 mutation in molecular biology which is compatible with the diagnosis of essential thrombocythemia. The patient started a treatment based on hydroxyurea (HYDREA) with a good clinical evolution and her platelet count was of 219000 elements/mm3. Conclusions: The association of systemic sclerosis and essential thromcythemia increase the gravity of digital thrombocytosis and ulcers. Their management in this particular case requires a multimodal approach using a combination of pharmacological and local treatments. C0540 A PEDIATRIC CASE OF ACUTE LYMPHOBLASTIC LEUKEMIA WITH MULTIPLE SINUS THROMBOSIS AND DEEP VEIN THROMBOSIS Y. Kilinc1 , D. Ay Tuncel1 , A. Tunc1 . 1 Cukurova University Pediatric Hematology, Turkey Background: Thrombosis is one of the common complications of leukemia related with disease or treatment. In this report, a case of acute lymphoblastic leukemia with cerebral sinus and deep vein thrombosis was presented. Methods: Case: 13 year old, male patient with shortness of breath and pallor is recoursed to Pediatric Hematology Clinic. On physical exam he was pale, has tachypnea and his spleen was palpated 8 cm below left costal margin and liver was 10 cm. Neurological examination was normal. On X-ray scanning, he has wide mediastinum. On his laboratory examination; analysis of the peripheral blood smear revealed lymphoblasts. He has diagnosed Acute Lymphoblastic Leukemia by bone marrow aspiration plus flow cytometry. BFM ALL chemotherapy protocol was begun. Evaluation of the patient, he was included in T-ALL HRG group. During the protocol 1 phase 1 chemotherapy, after a sudden headache, convulsion occurred. On cerebral MRI scanning, thrombus was demonstrated and occluded dural sinus. Searching for a thrombophilic state, homosistein was found high. During evaluation of the patient, deep vein thrombus at the lower extremity was also seen. Enoxaparin treatment was begun. Results: The patient is still under treatment of Leukemia but enoxaparin treatment was discontinued because of bleeding complications.
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
yellow color of the skin, mild purpura and pains all over the body. Physical and routine laboratory examination was performed. Additional tests such as peripheral blood smear, Coombs test and coagulation screening tests (TT, PTT and TT) were also performed. Results: The physical examination revealed high hart rate, fever and neurological symptoms (confusion and paresis). Laboratory tests showed anemia, thrombocytopenia and impaired renal function. The complete blood count (CBC) showed reduced number of red blood cells (1.8×1012 /L with hemoglobin level of 50 g/L) and thrombocytopenia (60×109 /L). Hemolytic anemia was confirmed with the fallowing findings: indirect bilirubin – 21.5 mmol/L (normal range: 5–13 mmol/L), high serum lactate dehydrogenase (LDH) – 1200 U/L (the normal range: 213–423 U/L), slide review of the blood smear indicated the presence of spherocytes, schistocytes and increased number of reticulocytes, direct Coombs test was negative. The coagulation tests were within the reference interval, as well as the level of von Willebrand factor. Renal dysfunction was presented with elevated serum creatinine of 156 mmol/L (normal range: 44– 116 mmol/L) and the presence of red and white blood cells, proteins and glucose in the urine. The patient benefited from the plasma exchange treatment with fresh frozen plasma and cryosupernatant plasma. Conclusions: The early onset with plasmapheresis although the diagnosis of TTP is only a presumptive one can be lifesaving therapy in cases with microangiopathic hemolytic anemia in the absence of other obvious causes. C0128 UNUSUAL PRESENTATION OF A LEFT ATRIAL THROMBUS MIMICKING A CARDIAC MYXOMA 1 M. Padilla Perez ´ , F. Almagro Torres1 , M. Sanchez de Castro1 , C. Lozano Cabezas1 , E. Vazquez Ruiz de Castroviejo1 , D. Salas Bravo1 , J. Torres Llergo1 , J. Carlos Fernandez Guerrero1 . 1 Spain
Background: In nonvalvular atrial fibrillation (AF), left atrial thrombi almost exclusively arise in the atrial appendage. However, some unusual presentations have been described, attached to the interatrial septum by a stalk, mimicking a cardiac myxoma. Surgical resection is recommended in myxomas, while oral anticoagulation is the first line therapeutic option for LA thombus. Methods: We present the case of a 76 year-old man with hypertension, referred for cardiovascular examination because of a first known episode of AF. There were no murmurs on cardiac auscultation. Transthoracic echocardiography (TTE) showed a markedly dilated left atrium (49 mm) and normal left ventricular systolic function. The left-sided cardiac valves moved appropriately. A mobile mass was identified, adjacent to the interatrial septum in the left atrium (LA) (Figures 1 and 2). On transesophageal echocardiography (TEE), a 15×14 mm mass was seen in the LA, and attachment to the interatrial septum by a stalk was confirmed. It had an irregular surface and heterogeneous appearance with a central hypoechoic area. No mass was seen in the LA appendage. In view of these observations, it could be either a myxoma or a thrombus. Oral anticoagulant therapy with warfarin was prescribed and a second echocardiographic examination after 4 weeks of treatment was performed, showing the absence of any intracardiac mass (Figures 3 and 4) confirming that it was indeed a thrombus. The patient had no thromboembolic events during that period of time. Results: Figures of the transthoracic and transesophageal echocardiogram will be displayed in the poster. Conclusions: Echocardiographic distinction between a thrombus and a myxoma in the LA is not always straightforward, and the clinical context must be taken into account. LA thrombi, which appear more frequently than cardiac myxomas, typically originate in the LA appendage, and generally occur in patients with AF, enlarged atrial chamber, prosthetic mitral valve or mitral stenosis.
However, some atypical LA thrombi have been described, attached by a stalk to the left atrial septal pouch in the fossa ovalis, and can be wrongly diagnosed as myxomas, leading to an unnecessary surgical resection. The key messages are: 1. In a LA mass with stalk, echocardiographic differential diagnosis between thrombus and myxoma may be difficult. 2. TEE should be performed for better definition of the mass characteristics, such as the shape, site of attachment, margins, and presence or absence of thrombus in the LA appendage 3. When the differential diagnosis remains difficult and thrombus is a possibility, such as in AF, a trial of anticoagulation may be advised before sending the patient to cardiac surgery. C0335 MEDIAN ARCUATE LIGEMENT SYNDROME AND THROMBOPHILIA: CASE REPORT D. Glavas1 , K. Novak1 . 1 Uni Hospital Split, Soltanska 1, Split, Croatia Background: Median arcuate ligament syndrome-MALS, also known as celiac artery compression syndrome or Dunbar syndrome, is characterized by nausea, vomiting and recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. Usually, in 1 /4 of healthy people, ligament pass under celiac artery, causing artery compression. The consequence could be decreasing in blood flow throughout abdominal organs and mesenteric artery. Methods: The diagnosis is often one of exclusion, given the non-specific symptoms which overlap with other forms of chronic intestinal ischemia, and include angiography and Doppler examination tests. Results: Our patient (53 year old female) was admitted to the hospital because of swelling of the left leg. After admission, ultrasound revealed thrombus of lower part of femoral vein with expansion to the popliteal and fibular vein. Besides, there was found an older thrombus in right common iliac vein. The initial treatment included enoxaparin and warfarin. Soon after admission, patient reported pain in the lower part of abdomen with headache, perspiration, and increasing in blood pressure. The abdominal ultrasound examination was orderly. Abdominal MSCT scan with angiography was also performed because of suspicion on embolism and thrombosis. The scan had shown that common hepatic artery and artery three came out of the aorta (instead of celiac truncus), and, after that, was branching on the lienal and left gastric artery as anatomical variation. Other tests included positive D-dimer test (2.52 mg/L; normal range 0–0.5 mg/L), and positive thrombophilia test (patient was heterozygote on factor V-Leiden). The treatment was continued with the same medication (enoxaparin and warfarin). The surgeon did not suggest the surgical intervention, because this was the first disease attack. After the hospital treatment, the patient was clinically better, and she was discharged with warfarin in therapeutic range (the value of INR was 2.5–3). Six month after the discharge, on control examination, the clinical profile was excellent. Conclusions: In everyday clinical practice, we should think that MALS could be associated with thrombophilia and thrombosis. C0348 ACUTE DEEP VENOUS THROMBOSIS ASSOCIATED WITH ACUTE BRUCELLOSIS: A CASE REPORT S. Salihi1 , M. Kalender1 , M. Tasar1 . 1 Nide State Hospital. Nide, Turkey Background: Brucellosis is a zoonotic disease common in developing countries. Vascular complications, including arterial and venous, associated with Brucella infection have rarely been reported. A case of deep venous thrombosis (DVT) developing after a diagnosis of acute brucellosis in a young milkman is presented.
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
Case presentation: A 26-year-old man presented with pain in the right leg. The patient’s medical history included a diagnosis of brucellosis in our hospital where he had presented with complaints of weakness and fever. Peripheral venous Doppler ultrasound showed DVT and patient was treated with anticoagulants. The patient was discharged with warfarin therapy and anti-brucellosis treatment. Conclusions: Although rare, some infectious agents may cause vascular pathologies. Patients presenting with symptoms of DVT or similar vascular pathologies should be assessed for infectious agents particularly in those coming from Brucella-endemic areas. C0466 TOTAL ABDOMINAL HYSTERECTOMY AND POSTOPERATIVE BLEEDING DIATHESIS: A CASE REPORT T. Vucemilo1 , M. Puljiz1 , I. Alvir1 , I. Mamic1 , M. Skoko1 . 1 University Hospital Sisters of Charity University Hospital for Tumors. Transfusion, Zagreb, Croatia Background: Uterine myoma is the most common benign genital tumor among women of reproductive age. Total abdominal hysterectomy (TAH) is the most common type of hysterectomy. The average blood loss during TAH is approximately 300ml. Surgical blood loss that requires a blood transfusion is usually defined as intraoperative hemorrhage. Intraoperative hemorrhage has been reported in 1% to 2% of hysterectomy studies. Methods: We present a case of TAH complicated with bleeding diathesis and blood loss more than 2500 ml. A 42-year-old woman 3-para had a five year history uterine myoma. Her past medical history was free of any medical problems. She was found to be anemic with Hg of 6.3 g/dl. Four days before surgery she had 600 ml packed red blood cells transfused. Before surgery her Hg was 10 g/dl. PLT 233x/l Coagulation parameters were normal: PT 12.6 s, APTT 29 s, TT 15 s, Fibrinogen 4.2 g/l. She underwent open myomectomy via a low transverse incision when the uterus found to be enlarged to the size of a 12-week pregnancy. The estimated blood loss was 300 ml and there were no complications. The patient was hemodinamically stable until the end of surgery. Three to four hours postoperatively she became dyspneic. She was hypotensive and tachycardic. Her Hg dropped to 5.4 g/l. She had remarkably prolonged coagulation parameters PT 23.5 s, INR 2.0, APTT 69 s, TT 27 s, Fibrinogen 1.0 g/l, PLT 60. Ultrasonography revealed free fluid filling the pelvis in lower abdomen. A diagnosis of intrabdominal bleeding was set and she underwent immediate laparotomy with appropriate resuscitation with i.v. fluid, blood, FFP, cryoprecipitate and ciclokapron. Results: At laparotomy an estimated 2000 ml of blood was found in the peritoneal cavity, and there was no evidence of active arterial bleeding. The total estimated blood loss during surgery was 2500 ml and patient received 2100 ml packed red blood cells, two unit FFP, two pools platelets, two dose cryoprecipitate 850 AHF, ciclokapron 1500 mg. Under supplementation of blood components subsequent laboratory finding improved with stabile vital sign and a satisfactory recovery. Conclusions: Bleeding diathesis can be caused by many solid tumors but TAH induced bleeding diathesis is rare. Recently published data demonstrates that women presented with menorrhagia frequently report an additional history of bleeding after surgery. We need additional efforts to develop hematological screening tools within women presenting with menorrhagia.
S57
C0536 DIGITAL MICROTHROMBOSIS IN SYSTEMIC SCLEROSIS: THINK ABOUT ESSENTIAL THROMBOCYTHEMIA F. Ajili1 , A. Tliba1 , N. Boussetta1 , H. Ghedira1 , I. Gharsallah1 , L. Metoui1 , B. Louzir1 , N. ben Abdelhafidh1 , S. Othmani1 . 1 Military Hospital in Tunis. Internal Medicine. Tunis, Tunisia Background: Digital microthrombosis are a well-known problem in patients with systemic sclerosis. Essential thrombocytosis is another cause of this disease. It causes digital ulcers which increase impairment of hand function. Methods: We report clinical charts of a female 68 year old patient with a rare association of essential thrombocythemia and systemic sclerosis. Results: A 68 year old women presented with a 2 week history of pain and bilateral bluish discoloration of the finger tips and toes, epigastric pain, post prandial vomiting, heartburn and dysphagia. Physical examination showed proximal skin sclerosis, thin skin, less hair, bilateral and symmetrical sclerodactily and pulp ulcers of ten fingers and the big toes. Abnormality in complementary investigations were platelet count of 634000 elements/mm3 in blood test, interstitel syndrome in chest radiography and resorption of phalangeal tufts of several fingers in hand radiographs. Then the diagnosis of systemic sclerosis was confirmed. The clinical outcome, after treatment with calcium channel blockers and colchicine, was marked by the extent of digital ulcers. On the other hand, the thrombocytosis was compounded. A bone marrow biopsy was done and concluded at a megakaryocytic lineage hyperplasia, and presence of JAk 2 mutation in molecular biology which is compatible with the diagnosis of essential thrombocythemia. The patient started a treatment based on hydroxyurea (HYDREA) with a good clinical evolution and her platelet count was of 219000 elements/mm3. Conclusions: The association of systemic sclerosis and essential thromcythemia increase the gravity of digital thrombocytosis and ulcers. Their management in this particular case requires a multimodal approach using a combination of pharmacological and local treatments. C0540 A PEDIATRIC CASE OF ACUTE LYMPHOBLASTIC LEUKEMIA WITH MULTIPLE SINUS THROMBOSIS AND DEEP VEIN THROMBOSIS Y. Kilinc1 , D. Ay Tuncel1 , A. Tunc1 . 1 Cukurova University Pediatric Hematology, Turkey Background: Thrombosis is one of the common complications of leukemia related with disease or treatment. In this report, a case of acute lymphoblastic leukemia with cerebral sinus and deep vein thrombosis was presented. Methods: Case: 13 year old, male patient with shortness of breath and pallor is recoursed to Pediatric Hematology Clinic. On physical exam he was pale, has tachypnea and his spleen was palpated 8 cm below left costal margin and liver was 10 cm. Neurological examination was normal. On X-ray scanning, he has wide mediastinum. On his laboratory examination; analysis of the peripheral blood smear revealed lymphoblasts. He has diagnosed Acute Lymphoblastic Leukemia by bone marrow aspiration plus flow cytometry. BFM ALL chemotherapy protocol was begun. Evaluation of the patient, he was included in T-ALL HRG group. During the protocol 1 phase 1 chemotherapy, after a sudden headache, convulsion occurred. On cerebral MRI scanning, thrombus was demonstrated and occluded dural sinus. Searching for a thrombophilic state, homosistein was found high. During evaluation of the patient, deep vein thrombus at the lower extremity was also seen. Enoxaparin treatment was begun. Results: The patient is still under treatment of Leukemia but enoxaparin treatment was discontinued because of bleeding complications.