Kulothungan Gunasekaran

Rectus sheath hematoma associated with apixaban

Apixaban is an oral anticoagulant that directly inhibits Factor Xa and is indicated for the prophylaxis and treatment of deep venous thrombosis and stroke prevention in non-valvular atrial fibrillation. Rectus sheath hematoma is a rare, life-threatening complication of anticoagulant treatment. We describe a case of an elderly patient on apixaban for the treatment of deep venous thrombosis who developed severe abdominal pain during hospitalization. Computed tomography of the abdomen revealed left rectus sheath hematoma. Apixaban was discontinued and the patient was monitored for extension of the hematoma. After 2 days she was discharged home. Outpatient computed tomography 1 month later showed complete resolution of the rectus sheath hematoma. We recommend that clinicians become aware of the potential for rare and serious bleeding complications of anticoagulants and identify the need for early recognition and prompt management.

Granulomatosis with polyangiitis (GPA) presenting as thick-walled cavitary lung lesion

A 58-year-old female with a history of psoriatic arthritis on immunosuppressive therapy presented to the clinic with flu-like symptoms, cough, and blood-tinged sputum for one week. She denied chills, night sweats, wheezing, chest pain, weight loss, joint pain, or muscle aches. She had smoked for 31 pack-years and quit 1 year earlier. She was born and lived in upstate New York with no previous exposure to tuberculosis (TB). She had no exposure to chemicals or bird or bat droppings. There was no recent history of travel to any fungal endemic areas. Her home medications included albuterol, fluticasone-salmeterol, montelukast, omeprazole and citalopram. Her physical examination was completely normal, and she had a white blood cell count of 13.8 10/l with a platelet count of 63 10/ml. She was prescribed amoxicillin/clavulanate for presumed pneumonia. Because of the persistence of symptoms, imaging studies were done. Chest x-ray showed a cavitary lesion with an air-fluid level in the right upper lobe (Figure 1A ). Computed tomography of the chest demonstrated a cavitary mass with irregular thick walls and air-fluid level, as well as a 1.1 0.8 cm rounded subpleural nodule in the anterior left upper lobe (Figure 1B). Bronchoscopic washings were negative for malignancy and infectious workup for bacteria including TB and fungi were negative. Biopsy of the left lung nodule showed extensive necrotizing suppurative granulomatous inflammation consistent with granulomatosis with polyangiitis. Her proteinase 3 ANCA levels were also elevated which supported the diagnosis. The patient was started on rituximab and prednisone with improvement in her symptoms. Differential diagnosis of a cavitary lesion in the lung is broad. Infectious causes include bacterial pathogen, fungal or TB infection. Noninfectious causes include malignancy and systemic inflammatory diseases, such as rheumatoid arthritis or granulomatosis with polyangiitis. Granulomatosis with polyangiitis is a multisystem disease that involves multiple organs especially the lungs and kidneys. The frequent lung manifestations are nodules and infiltrates. Cavitation of the nodules occurs in 25% of nodules when they are > 2 cm, and the presentation of a solitary cavitary lesion is a rare phenomenon.

Management of Elective Surgery and Emergent Bleeding with Direct Oral Anticoagulants

Purpose of ReviewThe purpose of this review was to offer practical management strategies for when patients receiving direct oral anticoagulants require elective surgery or present with bleeding complications.Recent FindingsClinical practice guidelines are now available on the timing of periprocedural interruption of treatment with the newer direct oral anticoagulants based on their pharmacodynamics and pharmacokinetics and based on findings from cohort studies and clinical trials. An antibody that reverses the effects of dabigatran is now available, and a factor Xa decoy is being developed as an antidote to apixaban, betrixaban, edoxaban, and rivaroxaban.SummaryThe timing of interruption of direct oral anticoagulants for elective surgery is based on multiple factors, including pharmacologic properties and interactions, the patient’s renal function, and the type of planned surgery. There is little role for low-molecular-weight heparin bridging. Idarucizumab is the treatment of choice for dabigatran-related life-threatening bleeding, while andexanet alfa is being developed to reverse factor Xa inhibitors.

Spontaneous thyroid hemorrhage on chronic anticoagulation therapy

Even though highly vascularized, the thyroid gland rarely has spontaneous bleeding. Bleeding into the thyroid gland can result in potentially lethal acute airway compromise. This case report describes an elderly patient on warfarin for atrial fibrillation, who presented with swelling on the right side of her neck causing acute airway obstruction. An urgent computed tomography of the neck showed an enlarging hemorrhage into the right lobe of the thyroid gland. She was initially intubated for airway protection and her anticoagulation was reversed to stop the bleeding. She was closely monitored in the intensive care unit. After an uncomplicated tracheal extubation and recovery, she was discharged and scheduled for an elective total thyroidectomy. We desire that physicians be aware of this rare, potentially lethal bleeding complication.