Correspondence

Disseminated Intravascular Coagulation

N Engl J Med 1999; 341:1937-1938December 16, 1999

Article

To the Editor:

In their excellent review of disseminated intravascular coagulation, Drs. Levi and ten Cate (Aug. 19 issue)1 suggest that a test for fibrin-degradation products be used in the diagnosis. They do not recommend that the d-dimer assay should be part of the initial workup in a patient suspected of having disseminated intravascular coagulation. The d-dimer assay measures insoluble cross-linked fibrin liberated by plasmin, which a priori indicates that both thrombin and plasmin have been formed, a sine qua non for disseminated intravascular coagulation.2

The authors also place undue emphasis on examination of the peripheral-blood smear for evidence of red-cell fragmentation. Although red-cell fragmentation has been described in patients with disseminated intravascular coagulation,3,4 it occurs in only a minority of patients and is a very nonspecific finding. Visudhiphan et al. found no difference in the degree of erythrocyte fragmentation between patients with sepsis who had disseminated intravascular coagulation and patients who had sepsis without disseminated intravascular coagulation.5 These data suggest that examination of the peripheral-blood smear for red-cell fragmentation does not help in the diagnosis of disseminated intravascular coagulation.

Alvin H. Schmaier, M.D.
University of Michigan, Ann Arbor, MI 48109-0640

5 References

1. 1

   Levi M, ten Cate H. Disseminated intravascular coagulation. N Engl J Med 1999;341:586-592
   Full Text | Web of Science | Medline

2. 2

   Marder VJ, Budzynski AZ. Degradation products of fibrinogen and crosslinked fibrin-projected clinical applications. Thromb Diath Haemorrhagica 1974;32:49-56
   Medline

3. 3

   Rosner F, Rubenberg ML. Erythrocyte fragmentation in consumption coagulopathy. N Engl J Med 1969;280:219-220
   Web of Science | Medline

4. 4

   Rappaport SI. Defibrination syndromes. In: Williams WJ, Beutler E, Erslev AJ, Rundles RW, eds. Hematology. New York: McGraw-Hill, 1972:1234-55.
   

5. 5

   Visudhiphan S, Piankijagum A, Sathayapraseart P, Mitrchai N. Erythrocyte fragmentation in disseminated intravascular coagulation and other diseases. N Engl J Med 1983;309:113-113
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The d-dimer assay may be considered one of the assays of fibrin-degradation products that are indeed helpful in the initial diagnostic workup for disseminated intravascular coagulation. We in fact specifically indicated that the d-dimer assay is an example of routinely available fibrin-degradation assays. Studies of the accuracy of this assay demonstrate a sensitivity for the diagnosis of disseminated intravascular coagulation of approximately 90 percent and a specificity of 80 percent.1 These values are slightly better than but of the same order of magnitude as the accuracy of other assays of fibrin-degradation products.

We do not agree that fragmented red cells (schistocytes) are present only in a minority of patients with disseminated intravascular coagulation. The article by Visudhiphan et al. indicated that fragmented erythrocytes were present in most patients with sepsis and disseminated intravascular coagulation.2 We agree, however, that the presence of schistocytes is not a specific finding; these cells may be present in many other conditions. We meant to use fragmented red cells as one example of the consequences of the intravascular deposition of fibrin and vascular-wall injury in patients with disseminated intravascular coagulation. Hence, we agree with Dr. Schmaier that examination of the blood smear for schistocytes cannot be considered an essential test in the initial diagnostic workup for disseminated intravascular coagulation.

Marcel Levi, M.D.
Hugo ten Cate, M.D.
University of Amsterdam, 1105 AZ Amsterdam, the Netherlands

2 References

1. 1

   Bick RL, Baker WF. Diagnostic efficacy of the D-dimer assay in disseminated intravascular coagulation (DIC). Thromb Res 1992;65:785-790
   CrossRef | Web of Science | Medline

2. 2

   Visudhiphan S, Piankijagum A, Sathayapraseart P, Mitrchai N. Erythrocyte fragmentation in disseminated intravascular coagulation and other diseases. N Engl J Med 1983;309:113-113
   Web of Science | Medline

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1. 1

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