Dabigatran-related axillary hematoma and coagulopathy in a patient with a pacemaker: The lesson we learned from a case report

Abstract

A 70-year-old man, a retired worker, had a history of hypertension and gouty arthritis. He was found to have irregular bradycardia with complete atrioventricular block 4 years previously, and he subsequently received a pacemaker. He was stable under dabigatran treatment (110 mg twice daily) until atrial fibrillation was found under the pacing rhythm 2 years later. Bisoprolol (5 mg) 0.5 tab QD and digoxin (0.25 mg) 0.5 tab QD were also prescribed 2 years ago. Thirteen days before admission, he helped mow the lawn around his home and suffered mild dehydration, left axillary pain and bruising. He denied any trauma or contusion. He went to our emergency room 10 days before admission due to an enlarged left axillary hematoma and limited movement of his left arm, and leukocytosis (WBC: 11,700/uL), elevated aPTT (61.8 seconds) and creatinine level (1.48 mg/dL) were found. Fresh frozen plasma (FFP) 6U was transfused and the aPTT decreased (43.2 seconds) the following day, when he was discharged from the emergency room and dabigatran was discontinued. Heparinoid gel was prescribed for the bruising, however it progressed over his left chest, upper arm and wrist with a left axillary tender, hot and swollen mass. He was therefore brought to our emergency room again 1 day before admission. He denied fever, chills, hematuria, bloody stool or bleeding gums. Under the impression of dabigatran-related coagulopathy and the suspicion of an infected hematoma, he was admitted (Table 1). As the bruising left axillary fusiform hematoma (11.4 cm in size) were suspected to be an infection, we administered an