[NP-Clinical] LAST questions/update on Kim's Opto husband -- long post

[Kimberly Spering]

So much for "resting easier"...another week from hell, for sure.  I am 
asking (hopefully one last time) for input from anyone familiar with 
patients post-pulmonary emboli and those with thrombophilias--more than a 
standard textbook has (hematology, or anyone who works with patients to 
diagnose/manage PE and/or thrombophilias in other settings).

My husband did NOT go home two days ago as planned post-DVT.  Temps were 
elevated 102+ for two days...Levaquin was changed to some IV cephalosporin 
and Zithromax.  After the second day, ID was consulted; Rocephin was 
started, work-up included Lyme disease titres (we were at the beach and in 
the woods at the in-laws' previously), Legionella antibodies, and a repeat 
CT scan of the chest.

Long story short...he was DEFINITIVELY diagnosed with a large right-sided PE 
(much of the descending artery--"ironically," at the area where he had all 
of his pain two weeks ago) AND definite emboli in the left base.  Given the 
current lack of SOB or respiratory s/s (other than O2 sats consistently at 
93%), all of the doctors feel strongly that the PE occurred before the first 
hospitalization.  A drug reaction rash subsequently developed (to heaven 
knows which drug)...and when the ID doc saw the CT scan and a WBC count of 
4.6, he immediately D/C'd all antibiotics...the fevers, presumably, have 
been due to the multiple PEs all along.  He was discharged this afternoon 
after almost 24 hours being afebrile (of course, his temp tonight is 101.0) 
and the Lovenox will continue till we can get his INR therapeutic.

So here are my questions:

1.  Factor V Leiden is pending, and I didn't hear what the result was for 
the Heparin antibody testing.  (Our office has hospital computer access, so 
I can get results next week).  Platelets are stable in the 120s.  HOWEVER, 
he has a low anti-thrombin III (AT III).  My medscape and webmd searches 
didn't shed a whole lot of information on this particular thrombophilia. 
Epocrates says it can be acquired (with major health issues, none of which 
he has), OR inherited.  The inherited part, apparently, is what the docs 
believe is the cause of the DVT to begin with.  Now that a PE is confirmed, 
the plan is Coumadin for 6 - 12 months; off for 10 days to do a full 
thrombophilia panel, and then see where we go from there.  Does anyone know 
if a protocol exists for Coumadin prophylaxis with patients with this low AT 
III?  They recommended screening our boys, but what would we do with this 
information for two 8 1/2 and almost 5 year old children?  I don't know how 
comfortable I'd be putting them on baby ASA, if that's even an option.

2.  How long might one expect to have a fever from a PE?  We didn't think to 
ask; the doctor told him to take Tylenol if he developed one, but I am 
wondering what's normal.  We will be talking with the on-call IM doc 
tomorrow, after his INR is drawn, so I plan to ask him/her then.

And of course, today, a doc I work with told me about an OB nurse who was 
"cleared" to come back to work post-DVT, who was found DEAD from a PE by her 
husband a few days later.  I guess knowing that Mark already HAS the PE and 
has been treated is better than wondering if a clot will migrate...but GEEZ! 
It wasn't the best supportive comment that I've heard in the past two weeks.

Thanks in advance...I just want to go hibernate for a while and find some 
peace-of-mind again...

Kim Spering