What clinical manifestations and laboratory findings are seen in patients with Disseminated Intravascular Coagulation (DIC)?

Clinical Manifestations and Laboratory Findings in Disseminated Intravascular Coagulation

DIC presents with a spectrum of clinical manifestations ranging from asymptomatic laboratory abnormalities to life-threatening bleeding or thrombosis, with three distinct subtypes: procoagulant (thrombotic), hyperfibrinolytic (bleeding), and subclinical (laboratory-only changes). 1

Clinical Manifestations by DIC Subtype

Procoagulant DIC (Thrombotic Presentation)

This is the most common subtype in adenocarcinomas, particularly pancreatic cancer and hepatocellular carcinoma 1, 2:

• Arterial complications: arterial ischemia, poor digital circulation, cerebrovascular events, peripheral neuropathy, ischemic colitis 1
• Venous complications: deep vein thrombosis, pulmonary embolism 1
• Microvascular thrombosis: severe purpura fulminans with acral ischemia, vascular skin infarction 3

Hyperfibrinolytic DIC (Bleeding Presentation)

Characteristic of acute promyelocytic leukemia and metastatic prostate cancer 1, 4:

• Widespread bruising and bleeding from mucosal surfaces 1
• Central nervous system hemorrhage 1
• Pulmonary hemorrhage 1
• Gastrointestinal bleeding 1
• Bleeding from trauma sites or surgical wounds 1

Subclinical DIC

No obvious clinical symptoms, only laboratory abnormalities 1, 4:

• Patients may appear asymptomatic despite significant coagulation activation 1
• A ≥30% drop in platelet count may be the only diagnostic sign, even when the absolute count remains normal 2

Laboratory Findings

Key Diagnostic Markers

The diagnosis requires finding abnormalities in at least 3 of 4 laboratory values 5:

• Decreasing platelet count (thrombocytopenia) 1, 4
• Elevated D-dimer levels (markedly elevated) 1, 4
• Prolonged coagulation screen (PT/aPTT) 1
• Decreased fibrinogen (hypofibrinogenemia) 1, 4

Important Diagnostic Caveats

• A normal platelet count does not exclude DIC in malignancy patients if there has been a profound decrease from a very high baseline level 1
• Abnormal coagulation screen is not always present in DIC 1
• Microangiopathic hemolytic anemia may be present 1
• Continuous thrombin generation can be detected through serial monitoring 1

Underlying Etiologies

DIC is always secondary to an underlying disorder 1:

• Malignancy (most common in cancer-associated DIC) 1
• Sepsis 1
• Trauma 1
• Complications of surgery and pregnancy 1
• Obstetric complications: abruptio placentae, amniotic fluid embolism, retained dead fetus, post-hemorrhagic shock 6

Monitoring Requirements

The frequency of laboratory monitoring depends on clinical severity 2, 4:

• Monthly monitoring for stable subclinical DIC 4
• Daily monitoring for acute bleeding or thrombotic presentations 4
• Regular blood counts, clotting screens, fibrinogen, and D-dimer are essential 2, 4
• Serial testing is mandatory to monitor the dynamically changing scenario 3