Management of Saddle Pulmonary Embolism in the Context of Heparin-Induced Thrombocytopenia and Granulomatosis With Polyangiitis

Heparin-induced thrombocytopenia (HIT) is a serious, immune-mediated complication of heparin therapy that paradoxically increases the risk of thrombosis while causing a significant reduction in platelet count. In this report, we present the case of a 65-year-old Caucasian female with a history of granulomatosis with polyangiitis (GPA) and acute kidney injury requiring dialysis who was admitted with progressive shortness of breath. Imaging confirmed the presence of a saddle pulmonary embolus and multiple segmental emboli, complicated by bilateral pulmonary infarcts. Given her history of HIT, direct thrombin inhibitors (DTIs) were initiated, with argatroban used in conjunction with warfarin. Close monitoring of anticoagulation was performed using activated partial thromboplastin time (APTT) and international normalized ratio (INR) trends. The case highlights the challenges of managing pulmonary embolism (PE) in the context of HIT and GPA, emphasizing the need for multidisciplinary decision-making and individualized anticoagulation strategies.