An Outbreak of Brodifacoum Coagulopathy Due to Synthetic Marijuana in Central Illinois

Abstract

Brodifacoum (BDF) is an anticoagulant found in rodent bait and is commonly used as a household rodenticide. It is known as a superwarfarin, with up to 100 times the potency of warfarin and a half-life of at least 16 days compared with 40 hours in warfarin.1Booth G.S. Mody P.Z. Brodifacoum inhalation and its clinical manifestations in a 21-year-old Caucasian man.Lab Med. 2016; 47: 63-66Crossref PubMed Scopus (9) Google Scholar It has been used in various hazardous situations including suicide, homicide, accidental and intentional ingestions, and more recently, in the lacing of recreational drugs. As of April 27, 2018, the Illinois Department of Public Health (IDPH) has received reports of 156 cases, including 4 deaths, due to BDF coagulopathy linked to K2.2Illinois Department of Public Health Synthetic cannabinoids.www.dph.illinois.govDate accessed: April 27, 2018Google Scholar We report a case of a 38-year-old white man with hematuria and hemoptysis due to a BDF coagulopathy from synthetic K2 marijuana use. A 38-year-old white man presented to the hospital after coughing up blood and noticing dark urine for 2 days. He denied a history of anticoagulation use, bleeding disorders, and exposure to rat poisoning. He did, however, admit to smoking K2 synthetic marijuana 2 weeks previously. He reported smoking K2 regularly for at least 3 to 4 years, but these symptoms had never occurred in the past. Although his hemoglobin was normal at 15 g/dL, he had an international normalized ratio greater than 10, a prothrombin time greater than 150 seconds, and a partial thromboplastin time of 54 seconds. An anticoagulant poisoning panel was positive for BDF in his blood. The patient's case was reported to the IDPH and was discussed with poison control. The patient was initially given intravenous vitamin K and was transitioned to oral vitamin K (phytonadione) the following day. Because of the long half-life of BDF, poison control recommended that the patient be discharged on phytonadione twice a day for at least 1 month. Brodifacoum poisoning is known to cause severe, long-lasting bleeding events up to months due to the prolonged half-life. Brodifacoum is stored in lipids and can be released over long periods of time, requiring prolonged therapy with vitamin K1.3Anderson S. Kattappuram R.S. Marrs J.C. Joseph N.M. Intentional brodifacoum ingestion.Am J Med. 2017; 130: e27-e28Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The proposed rationale for intentional lacing of synthetic marijuana with BDF is that it enhances the effect and prolongs the high of the drug because of the way it is stored. Currently, there are no United States Food and Drug Administration (FDA)-approved drugs that can completely eliminate BDF from tissues. The mainstay of therapy includes oral vitamin K1. Patients are being discharged with 100 mg (20 tablets) of phytonadianone daily. A month supply costs around $37,000. Because of concern for cost, some patients have been purchasing non–FDA-approved products online that claim to contain vitamin K1. These patients are admitted to the hospital for only a few days, and therefore, most of the management falls on the primary care providers. It is essential to educate these patients on the importance of establishing outpatient care and following up with a physician because many of them do not regularly do so. It is vital to inform the public of the long-lasting effect of this drug and that individuals would be at risk for severe bleeding events if they do not seek medical treatment. Finally, clinicians should be aware of this outbreak and the subsequent management of the coagulopathy.