Warfarin

Reactions 1478, p38 - 16 Nov 2013 S Warfarin Intrahepatic and subgaleal haemorrhage: case report A woman in her 20s developed simultaneous intrahepatic and subgaleal haemorrhages during treatment with warfarin for recurrent deep vein thrombosis (DVT). The patient was first diagnosed with a DVT at 18 years of age in March 2004, for which she received warfarin for 2 years. Four months after this treatment was ceased, she developed another DVT in November 2006. At this time she was diagnosed with antiphospholipid syndrome (APS) and then received anticoagulation therapy with warfarin [dosage and route not stated]. After 40 months of treatment, she was admitted in April 2010 with headache, fever, chills and epigastric pain. Her body temperature was 38.2°C. Laboratory tests showed the following values: WBCs 17 111 /mm 3 , segmental neutrophils 82.9%, Hb 9.7 g/dL, platelets 136 000 /mm 3 , CRP 8.38 mg/dL, ALP 211 I/U, PT INR 1.82 and aPTT 31.4 s. She had multiple low attenuated lesions without peripheral enhancement and perilesional oedema of the liver on a contrast-enhanced image as seen on her abdominal CT scan. A brain MRI revealed a crescentic high signal in the posterior parietal scalp on the T2 weighted image and mild enhancement on contrast-enhanced scan images. An intraparenchymal haemorrhage of the liver and a subgaleal haematoma were suspected as bleeding complications from her anticoagulation therapy. Warfarin was stopped and the woman was received antibiotics. Following 2 weeks of supportive care, US on day 16 demonstrated resolution of her hepatic lesions. Warfarin was restarted due to her recurrent thrombotic episodes. The woman was readmitted in June 2010 with pain in her right flank. A physical examination revealed abdominal tenderness in her right upper quadrant. Laboratory results showed the following values: WBCs 13 250 /mm 3 , segmental neutrophils 80.8%, Hb 10.2 g/dL, platelets 88 000 /mm 3 , CRP 7.93 mg/dL, PT INR 1.53 and aPTT 29.8 s. A low attenuated lesion in the S2/4 and S5 segments of her liver was seen on an abdominal CT scan. She was diagnosed with intraparenchymal haemorrhage of the liver from her anticoagulation therapy and warfarin was stopped. On day 17, a CT can showed nearly complete improvement of the intraparenchymal haemorrhage. One month later, a follow-up US showed the previous intrahepatic lesions were completely resolved. Clopidogrel and hydroxychloroquine were initiated in place of warfarin. She has not developed recurrent thrombotic episodes or bleeding complications. Author comment: "This is the first case with simultaneous bleeding in the liver and brain in an APS patient treated with warfarin." Park I-C, et al. Simultaneous intrahepatic and subgaleal hemorrhage in antiphospholipid syndrome following anticoagulation therapy. World Journal of Gastroenterology 19: 6494-6499, No. 38, 14 Oct 2013. Available from: URL: http://dx.doi.org/10.3748/wjg.v19.i38.6494 - South Korea 803095569 1 Reactions 16 Nov 2013 No. 1478 0114-9954/13/1478-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved

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Transcript of Warfarin

Reactions 1478, p38 - 16 Nov 2013

SWarfarin

Intrahepatic and subgaleal haemorrhage: casereport

A woman in her 20s developed simultaneous intrahepaticand subgaleal haemorrhages during treatment with warfarinfor recurrent deep vein thrombosis (DVT).

The patient was first diagnosed with a DVT at 18 years of agein March 2004, for which she received warfarin for 2 years.Four months after this treatment was ceased, she developedanother DVT in November 2006. At this time she wasdiagnosed with antiphospholipid syndrome (APS) and thenreceived anticoagulation therapy with warfarin [dosage androute not stated]. After 40 months of treatment, she wasadmitted in April 2010 with headache, fever, chills andepigastric pain. Her body temperature was 38.2°C. Laboratorytests showed the following values: WBCs 17 111 /mm3,segmental neutrophils 82.9%, Hb 9.7 g/dL, platelets136 000 /mm3, CRP 8.38 mg/dL, ALP 211 I/U, PT INR 1.82 andaPTT 31.4 s. She had multiple low attenuated lesions withoutperipheral enhancement and perilesional oedema of the liveron a contrast-enhanced image as seen on her abdominal CTscan. A brain MRI revealed a crescentic high signal in theposterior parietal scalp on the T2 weighted image and mildenhancement on contrast-enhanced scan images. Anintraparenchymal haemorrhage of the liver and a subgalealhaematoma were suspected as bleeding complications fromher anticoagulation therapy.

Warfarin was stopped and the woman was receivedantibiotics. Following 2 weeks of supportive care, US onday 16 demonstrated resolution of her hepatic lesions.Warfarin was restarted due to her recurrent thromboticepisodes.

The woman was readmitted in June 2010 with pain in herright flank. A physical examination revealed abdominaltenderness in her right upper quadrant. Laboratory resultsshowed the following values: WBCs 13 250 /mm3, segmentalneutrophils 80.8%, Hb 10.2 g/dL, platelets 88 000 /mm3, CRP7.93 mg/dL, PT INR 1.53 and aPTT 29.8 s. A low attenuatedlesion in the S2/4 and S5 segments of her liver was seen on anabdominal CT scan. She was diagnosed with intraparenchymalhaemorrhage of the liver from her anticoagulation therapy andwarfarin was stopped. On day 17, a CT can showed nearlycomplete improvement of the intraparenchymal haemorrhage.One month later, a follow-up US showed the previousintrahepatic lesions were completely resolved. Clopidogreland hydroxychloroquine were initiated in place of warfarin.She has not developed recurrent thrombotic episodes orbleeding complications.

Author comment: "This is the first case with simultaneousbleeding in the liver and brain in an APS patient treated withwarfarin."Park I-C, et al. Simultaneous intrahepatic and subgaleal hemorrhage inantiphospholipid syndrome following anticoagulation therapy. World Journal ofGastroenterology 19: 6494-6499, No. 38, 14 Oct 2013. Available from: URL:http://dx.doi.org/10.3748/wjg.v19.i38.6494 - South Korea 803095569