Phenprocoumon/rivaroxaban/tinzaparin sodium

Abstract

Anaemia, haematomas at injection site and lack of efficacy: case report A 49-year-old woman developed anaemia and haematomas at injection site during treatment with rivaroxaban and tinzaparin sodium, respectively. Additionally, she exhibited lack of efficacy while receiving phenprocoumon as anticoagulant [not all dosages, routes and duration of treatment to reactions onsets stated]. The woman with migraine presented with a recent history of recurrent deep venous thrombosis (DVT) and subsegmental pulmonary emboli (PE). Ventricular fibrillation was seen and resuscitation was initiated. She was intubated. After four shocks, return of spontaneous circulation was noted. Quick-look transthoracic echocardiography (TTE) revealed signs of right ventricle-pressure overload. She was transferred to the ICU for further investigations and treatment. Her complaints had started 7 months before and she was diagnosed with DVT. She was immediately started on anticoagulant therapy with rivaroxaban 20 mg/day and was quickly discharged. After 3 months, she presented to the ED with vaginal bleeding, dizziness, and diplopia. Abdominal and vaginal palpation showed an enlarged mobile lump just below the umbilicus, leading to suspicion of myomatous uterus. Laboratory results showed severe anaemia and transvaginal sonography (TVS) showed uterine myomas. The woman received a blood transfusion. She also received lynestrenol [Orgametril] and leuprorelin [Lucrin]. On follow-up visits, she reported improvement in exercise tolerance. After 5 months, the dose of rivaroxaban was reduced to 10 mg/day. However, she continued to complain of vaginal blood loss. Meanwhile, a repetitive TVS revealed another ovarian abnormality. Four weeks later, she was readmitted with recurrent DVT and pulmonary embolism (PE). Rivaroxaban dosage was increased to 20mg and she was discharged. Two weeks following this event, she underwent the MR pelvis, which led to suspicion for ovarian malignancy next to adenomyosis uteri. CT-abdomen confirmed a solid multilocular lesion suspect for ovarian carcinoma. Following various investigations, concurrently non-bacterial thrombotic endocarditis (NBTE) was suspected, in the setting of a metastatic adenocarcinoma. Altogether, ventricular fibrillation secondary to a previous myocardial infarction following coronary embolisation from NBTE in the setting of metastatic ovarian cancer was diagnosed. After the diagnosis of NBTE, rivaroxaban was replaced by SC tinzaparin sodium [tinzaparin, a low molecular weight heparin] 175 IU/kg/day injection. In the outpatient setting tinzaparin sodium was replaced with phenprocoumon [fenprocoumon] after she complained of haematomas at the injection site of the tinzaparin sodium. Signs of DVT recurred while on phenprocoumon (lack of efficacy) and she was put on tinzaparin sodium once again. She underwent chemotherapy and various surgeries. Afterwards, she was doing relatively well. She had no signs of recurrent thromboembolism or heart failure.