Superwarfarin and Glass Ingestion with Prolonged Coagulopathy Requiring High-Dose Vitamin K1Therapy

Foreign Glass Bodies in Pleura and Pancreas: Systematic Review for Entry Hypotheses and Treatment Options in an Unresolved Case

BACKGROUND

Foreign bodies within the pleura and pancreas are infrequent, and the approaches to their treatment still a subject of debate. There is limited knowledge particularly regarding glass foreign bodies.

METHODS

We present a case involving large glass splinters in the pleura and pancreas, with an unknown entry point. In addition, a systematic review was conducted to explore entry hypotheses and management options.

RESULTS

In addition to our case, our review uncovered eight incidents of intrapleural glass, and another eight cases of glass in other intrathoracic areas. The fragments entered the body through impalement (81%), migrated through the diaphragm after impalement (6%), or caused transesophageal perforation (19%) following ingestion. Eight instances of glass inside the abdominal cavity were documented, with seven resulting from impalement injuries and one from transintestinal migration. There were no recorded instances of glass being discovered within the pancreas. Among the 41 nonglass intrapancreatic foreign bodies found, sewing needles (34%) and fish bones (46%) were the most common; following ingestion, they had migrated through either a transgastric or transduodenal perforation. In all these cases, how the foreign bodies were introduced was often poorly recalled by the patient. Many nonglass foreign bodies tend to become encapsulated by fibrous tissue, rendering them inert, though this is less common with glass. Glass has been reported to migrate through various tissues and cavities, sometimes with a significant delay spanning even decades. There are cases of intrapleural migration of glass causing hemothorax, pneumothorax, and heart and major blood vessels injury. For intrapleural glass fragment management, thoracoscopy proved to be effective in 5 reported cases, in addition to our patient. Most intrapancreatic nonglass foreign bodies tend to trigger pancreatitis and abscess formation, necessitating management ranging from laparoscopic procedures to subtotal pancreatectomy. There have been only four documented cases of intrapancreatic needles that remained asymptomatic with conservative management. There is no direct guidance from the existing literature regarding management of intrapancreatic glass foreign bodies. Consequently, our patient is under observation with regular follow-ups and has remained asymptomatic for the past 2 years.

CONCLUSIONS

Glass foreign bodies in the pleura are rare, and our report of an intrapancreatic glass fragment is the first of its kind. Impalement is the most likely method of introduction. As glass has significant migration and an ensuing complication potential, preventive removal of intrapleural loose glass should be considered. However, intrapancreatic glass fragment management remains uncertain.

Rodenticide poisoning leading to cerebral hemorrhage: A case report

RATIONALE

Anticoagulant rodenticides (ARs) are a substantial fraction of murine types. AR poisoning causes bleeding from the skin, mucous membranes, and multiple organs. However, reports of AR-induced cerebral hemorrhage are scarce.

PATIENT CONCERNS

A 40-year-old male presented with dizziness, headache, and limb weakness for 5 days and with coagulopathy. Two days prior to the onset of these symptoms, the patient was exposed to dead mice.

DIAGNOSES

Rodenticide intoxication-induced cerebral hemorrhage.

INTERVENTIONS

Vitamin K1 infusion, administration of dehydrating agents to reduce intracranial pressure, and correction of acid-base and electrolyte imbalances.

OUTCOMES

After 9 days of treatment, the patient's symptoms were relieved, and reexamination revealed that coagulation parameters returned to normal levels. The patient was eventually discharged for observation with oral vitamin K1.

CONCLUSIONS

Rodenticide poisoning can lead to intracerebral hemorrhage, and treatment with vitamin K1 infusion is effective.

LESSON

Rodenticide poisoning-induced cerebral hemorrhage is rarely reported. Because its symptoms are nonspecific, it is easy to miss the diagnosis or misdiagnose. When patients present with direct and indirect symptoms such as dizziness, headache, and limb weakness, rodenticide poisoning should be considered. Coagulation function and head computed tomography or magnetic resonance imaging examination should be performed at the earliest to confirm the diagnosis and provide timely treatment.

Reversible leukoencephalopathy caused by 2 rodenticides bromadiolone and fluoroacetamide: A case report and literature review

RATIONALE

With the easy access, rodenticide poisoning has been a public health problem in many countries. Characteristics of central nervous system (CNS) lesions induced by rodenticides are scarcely reported.

PATIENT CONCERNS

We presented a case of a 40-year-old man with seizure and consciousness disorder, coagulation dysfunction, and symmetric lesions in white matter and corpus callosum.

DIAGNOSIS

He was diagnosed with rodenticide poisoning due to bromadiolone and fluoroacetamide.

INTERVENTIONS

He was treated with vitamin K, hemoperfusion, acetamide, and calcium gluconate.

OUTCOMES

His leukoencephalopathy was reversed rapidly with the improvement of clinical symptoms.

LESSONS

This report presented the impact of rodenticide poisoning on CNS and the dynamic changes of brain lesions, and highlighted the importance of timely targeted treatments.

Treatment for long acting anticoagulant rodenticide poisoning - beyond INR monitoring?

Poisoning by long acting anti-coagulant rodenticides (LAARs) requires long-term treatment with oral vitamin K1 (VK1). However, discontinuing treatment based on normalization of INR, may leave some patients with serum LAAR concentrations above a level considered safe. To address this, we carried out a retrospective analysis of 21 case reports of LAAR poisoning having at least two serum LAAR concentrations quantified during treatment with oral VK1. We identified the case reports by survey of existing peer-reviewed literature in which a patient presented to emergency department exhibiting bleeding or elevated INRs, and had quantitative measurements of serum LAAR concentrations. Of 21 case reports, measurement of serum LAAR concentrations following VK1 treatment showed that over half (n=11) had serum LAAR concentrations that were above a concentration considered to be safe (10 ng/mL), despite having received higher daily and total VK1 dosing, over an equivalent treatment duration. Since residual amounts of serum and tissue LAAR could contribute to symptom recurrence and repeated hospitalization, these results indicate that normalization of INR is not a sufficient criterion to discontinue VK1 treatment and that measurements of serum LAAR concentrations should be included to help guide decisions to continue or discontinue VK treatment.

A guide to acquired vitamin K coagulophathy diagnosis and treatment: the Russian perspective

Abstract

Physicians often come across with cases of vitamin K antagonists–dependent coagulopathy for reasons such as accidental use of the vitamin K antagonists (VKA), excessive administration of prescribed anticoagulants of indirect action or not reported administration of vitamin K antagonists due to memory impairment and/or other mental disorders, even deliberate use thereof (attempt to murder or suicide). Rodenticide-poisoning (coumarins, warfarins) via food or occupational accidents are difficult to diagnose. This article discusses different types of acquired vitamin K-dependent coagulopathy. Differential diagnosis is primarily based on patient statements before additional causes of vitamin K deficiency are explored. Even when pathological vitamin K deficiency is not determined, appropriate and urgent medical treatment is necessary: administration of fresh frozen plasma or concentrated factors of the prothrombin complex, administration of vitamin K remedies along with symptomatic therapy. With early diagnosis and prescription of appropriate therapy, prognosis is favorable.

Graphical abstract

Reasons for vitamin K antagonists–dependent coagulopathy cases

Treatment of a long-acting anticoagulant rodenticide poisoning cohort with vitamin K1 during the maintenance period

Currently, there are few guidelines for the use of vitamin K1 in the maintenance treatment of long-acting anticoagulant rodenticide (LAAR) poisonings. We explored factors in the treatment of LAAR poisoning during the maintenance period in order to suggest feasible treatment models.Data from 24 cases of anticoagulant rodenticide poisoning in our hospital were collected from January 2013 to May 2016. The patients' sex, age, coagulation function, total time from poisoning to treatment with vitamin K1 (prehospital time), vitamin K1 sustained treatment time (VKSTT), anticoagulant rodenticide category, and specific poison dosage were collected. Multivariate analysis was used to evaluate the correlation between vitamin K1 dosage and other factors during the maintenance period.Only VKSTT (partial regression coefficient -1.133, 0.59, P = 0.035) had an obvious influence on the therapeutic dose of vitamin K1 required during the maintenance period.After an initial pulse therapy, the bleeding and coagulation functions were stabilized, and the patients were subsequently treated with vitamin K1 during the maintenance period. Over time, the maintenance dose of vitamin K1 (10-120 mg/d, intravenous drip) was gradually decreased and was not related to toxicant concentration.

Treatment of vitamin K-dependent coagulation factor deficiency and subarachnoid hemorrhage

BACKGROUND

In adults, vitamin K-dependent coagulation factor deficiency (VKCFD) increases in the recent years. We treated a VKCFD patient with subarachnoid hemorrhage, with favorable outcomes.

METHODS

A 19-year-old male student with VKCFD was treated at our hospital. The initial treatment was injection of a large dose of vitamin K and fresh plasma, and then with oral high dose of vitamin K4.

RESULTS

At 4 weeks after admission, the focus of hemorrhage subsided, neurological examination was normal, and the patient was discharged.

CONCLUSIONS

VKCFD is rare and its diagnosis should be based on the history of the patient and the results of laboratory examinations. A large dose of vitamin K is the first choice of treatment.

Bromadiolone toxicokinetics: diagnosis and treatment implications

INTRODUCTION

Ingestion of bromadiolone can lead to prolonged and life-threatening coagulopathy. Traditional treatment of bromadiolone intoxication relies on the coagulation profile. Currently, there is scanty information on bromadiolone elimination kinetics and half-life.

CASE REPORT

We report a case of bromadiolone poisoning in a 40-year old female who, by history, ingested four 42.5-gram bags of rat poison (0.005% bromadiolone), equivalent to 8.5 mg bromadiolone (0.17 mg/kg body weight), four days prior to admission. On admission, her prothrombin time was 92.0 seconds, international normalized ratio was 5.7, and activated partial thromboplastin time was 50.2 seconds with no bleeding on clinical examination. The first plasma bromadiolone level (5 days post-ingestion) was 92 ng/mL. Serial measurement of plasma bromadiolone levels confirmed the diagnosis and demonstrated that bromadiolone obeys the elimination kinetic of a two-compartment model with a rapid, fairly steep decline phase (half-life 3.5 days) followed by a slower termination phase (half-life 24 days). Plasma bromadiolone level of less than 10 ng/mL in our patient was associated with a consistently normal coagulation profile without vitamin K1 therapy.

CONCLUSIONS

There is a lack of information on the toxicodynamics and toxicokinetics of bromadiolone in humans; further studies are needed before the plasma bromadiolone level can serve as one of the logical and safe therapeutic endpoints for vitamin K1 therapy.

Long-acting anticoagulant rodenticide poisoning: An evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposure to long-acting anticoagulant rodenticides (LAAR). An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses. 1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the doses reported (Grade D). 2) Patients with symptoms of LAAR poisoning (e.g., bleeding, bruising) should be referred immediately to an emergency department for evaluation regardless of the doses reported (Grade C). 3) Patients with chronic ingestion of LAAR should be referred immediately to an emergency department for evaluation of intent and potential coagulopathy (Grade B). 4) Patients taking anticoagulants therapeutically and who ingest any dose of a LAAR should have a baseline prothrombin time measured and then again at 48-72 hours after ingestion (Grade D). 5) Patients with unintentional ingestion of less than 1 mg of LAAR active ingredient can be safely observed at home without laboratory monitoring. This includes practically all unintentional ingestions in children less than 6 years of age (Grade C). 6) Pregnant patients with unintentional exposure to less than 1 mg of LAAR active ingredient should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED or clinic is not required (Grade D). 7) Patients with unintentional ingestion of 1 mg or more of active ingredient and are asymptomatic should be evaluated for coagulopathy at 48-72 hours after exposure (Grade B). 8) Physicians' offices or outpatient clinics must be able to obtain coagulation study results in a timely manner, preferably in less than 24 hours, for patients who require outpatient monitoring (Grade D). 9) Gastrointestinal decontamination with ipecac syrup or gastric lavage is not recommended (Grade D). 10) Transportation to an emergency department should not be delayed for administration of activated charcoal (Grade D). 11) Patients with dermal exposures should be decontaminated by washing the skin with mild soap and water (Grade D). 12) The administration of vitamin K is not recommended prior to evaluation for coagulopathy (Grade D).