A case of combined Protein C and S deficiency?
Patient T.E.- 48 y/o wf referred with history of DVT referred to Hematology Clinic after initial hypercoaguable work-up by internist (ATIII, Protein C, Protein S levels) revealed "Protein C and S deficiency."
Would you leave her on Coumadin life-long?
This is a typical scenario where the seasoned internist remembers from residency training to order for ATIII, Protein C and S but has forgotten that: (a) you should not order Protein C or S while on Coumadin (b) there is a hypercoaguable state now known far more common than Protein C, ATIII and Protein S deficiency combined- FV Leiden (as well as PT 20,210). She was tested for FV Leiden while on Coumadin by the RAPC ratio which was 1.6, a PCR confirmed heterozygote state. She has elected to stay on Coumadin though she was counseled that the risk of fatal bleeding was probably equivalent to the risk of fatal clotting in this case of a prior DVT.
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