LAUSR

Introduction: Disseminated intravascular coagulation (DIC) is a well-known acquired coagulopathy associated with many underlying causes. The mainstay of treatment of this disease is identification and treatment of the underlying disorder, however, determination of the causative agent can sometimes be a challenging endeavor. Description: The patient in this case is a 79-year-old male who presented with generalized weakness for 3 days. His past medical history is significant for atrial fibrillation, wolff-ParkinsonWhite syndrome, renal cell carcinoma s/p partial left nephrectomy 13 months prior to presentation, and glioblastoma multiforme s/p resection 3 months prior to presentation. His medications include warfarin, and temozolomide. Vital signs on presentation include a temp of 36.8 Celsius, HR of 81, RR of 26, BP of 95/69, oxygen sat of 99% on room air. Labs revealed a platelet count of 6 x109/L (ref 135-317 x 109/L), INR of 3.0 (ref 0.8-1.1), Prothrombin time of 31.8 sec (ref 11.6-14.7 sec), D-dimer >42000 ng/ml (ref < 500ng/ml), positive soluble fibrin monomers, and a fibrinogen level <60 mg/dL (ref 200393 mg/dL). The patient was treated with supportive measures of platelet transfusions, packed red blood cell transfusions, and cryoprecipitate transfusions, broad spectrum antibiotics, and discontinuation of temozolomide. We monitored D-dimer and fibrinogen levels every 4 hrs, and despite appropriate therapy there was no improvement. A computed tomography (CT) scan of the abdomen was obtained in search of other etiologies for DIC. The CT scan revealed a mass in the left kidney measuring 2.4 cm, which likely represented a recurrence of his renal cell carcinoma (RCC), without additional identifiable metastatic disease. The DIC was refractory to supportive therapy and the patient was not a surgical candidate in the presence of fulminant DIC. Upon discussion of prognosis, the family elected for comfort care only. Discussion: Per literature review, RCC has rarely been associated with DIC. However, when DIC is observed in RCC, it is typically associated with metastatic liver disease and presents as chronic rather than acute fulminant DIC. This case presents a rare and uniquely aggressive presentation of RCC associated fulminant DIC that lead to death of the patient within 8 days of presentation.