Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin

Acute kidney injury from presumptive intramural ureteral hemorrhage secondary to diphacinone rodenticide exposure in a dog

OBJECTIVE

To describe the clinical features and outcome of a dog with anticoagulant rodenticide (diphacinone) exposure, which was subsequently diagnosed with a coagulopathy characterized by hemoperitoneum, and presumptive ureteral wall hemorrhage contributing to acute kidney injury (AKI).

CASE SUMMARY

A 4-year-old, female neutered Australian Cattle Dog was evaluated for an acute onset of lethargy, decreased appetite, and a mild right thoracic limb lameness. Radiographs and point of care ultrasound demonstrated retroperitoneal and peritoneal effusion. Diagnostic abdominocentesis confirmed hemorrhagic effusion. Complete blood count, biochemistry, and coagulation profile showed a regenerative anemia (PCV 32%), thrombocytopenia (platelets 96 × 10⁹ /L [96 × 10³ /µl]), azotemia (BUN 38.9 mmol/L [109 mg/dl], creatinine 512.8 µmol/L [5.8 mg/dl]), and coagulopathy (prothrombin time >100 s, activated partial thromboplastin time >42.3 s). The client reported access to anticoagulant rodenticide up to 72 hours prior to presentation. Ultrasonographic examination revealed bilateral pyelectasia and hydroureter with thickened distal ureteral walls at the level of the ureteral-vesicular junctions. The ultrasonographic conclusion was presumptive intramural ureteral hemorrhage resulting in ureteral obstruction. The patient was diagnosed with AKI with likely prerenal, renal, and postrenal components. Treatment included vitamin K and frozen plasma transfusion. The patient recovered fully and was discharged 3 days after presentation. Two days after discharge, the patient had improvement in azotemia (BUN 10.7 mmol/L [30 mg/dl], creatinine 176.6 µmol/L [2.0 mg/dl]). Gas chromatography-mass spectrometry confirmed presence of diphacinone in the blood. Repeat ultrasound and biochemistry 60 and 210 days, respectively, after discharge showed resolution of ureteral wall thickening, hydroureter, pyelectasia, and recovery of kidney parameters.

NEW OR UNIQUE INFORMATION

Although nephropathies secondary to anticoagulant therapy have been described in people, the authors believe this is the first report of diphacinone anticoagulant rodenticide exposure contributing to an AKI secondary to obstruction from ureteral wall hemorrhage in the veterinary literature.

Iliopsoas Haematoma: An Uncommon Differential Diagnosis for Groin Pain

Bleeding complications should be considered in the differential diagnosis of any patient on warfarin therapy. A 66-year-old man presenting with right groin pain due to a spontaneous iliopsoas hematoma is reported. Computed tomography of the abdomen and pelvis at the emergency department confirmed the diagnosis. Fresh frozen plasma was given to correct the clotting derangement. The patient was managed conservatively. He was subsequently discharged well without complication. Iliopsoas haematoma or spontaneous retroperitoneal haemorrhage is an uncommon complication that needs to be considered in the differential diagnosis of a patient on warfarin therapy with abdominal, flank or groin pain.

Nontraumatic Retroperitoneal Hematoma After Warfarin Administration: Fatal Case Report and Review of the Literature

Spontaneous retroperitoneal hematoma after warfarin therapy is an extremely rare event. Here, we report a 25-year-old man who was brought in to the emergency service with confusion. On arrival, the patient had hypotension, tachycardia, tachypnea, low-grade fever, and Glasgow Coma Scale score of 12. Abdominal examination revealed distention and mild tenderness in the right upper quadrant of the abdomen. The patient had a history of aortic valve replacement surgery and was on warfarin treatment at an international normalized ratio of 2.4. Our patient progressed to cardiorespiratory arrest. The resuscitation was initiated promptly. Despite all resuscitation measures, including transfusion and administration of high doses of catecholamine, the patient died of hypovolemic shock 3 hours after admission. At autopsy, the external surface of the abdominal great vessels (descending aorta and mesenteric vessels) showed scattered petechial hemorrhages without any visible site of perforation. After comprehensive exploration of the abdomen, no evidence of traumatic event was identified and the cause of internal blood loss was noted as warfarin adverse effect.