TEG-Platelet Mapping-Guided Evaluation of Anti-Phospholipid Carrier with Unusual Clinical Presentation and Paradoxical Laboratory Findings

Anti-phospholipid syndrome is defined by the combination of clinical thrombosis and detection of persistent anti-phospholipid antibodies (aPL), including lupus anti-coagulant (LA). Those who do not meet full clinical criteria of overt thrombosis but still harbor circulating aPL can be characterized as "anti-phospholipid carriers." Regardless of clinical manifestations, aPL can complicate coagulation testing, most commonly by elevating activated partial thromboplastin time (aPTT) and potentially obscuring additional coagulation defects. Platforms for global assays of hemostasis such as thromboelastography (TEG), especially in cases of complex (multiple) coagulopathies, grant a wider scope of detection to help guide more specific probing of individual defects. We report a case of an anti-phospholipid carrier initially evaluated with TEG, revealing paradoxical results suggesting multiple coagulation defects rather than the expected hypercoagulability characteristic of aPL. Directed follow-up testing revealed the patient had an antibody-mediated platelet defect as well as decreased factor XII activity. We present this case as an uncommon manifestation of aPL detected via TEG.