SPONTANEOUS HEMOTHORAX SECONDARY TO APIXABAN

Abstract

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Hemothorax is usually related to chest trauma or iatrogenic from procedures such as central lines, thoracentesis [1]. Spontaneous hemothorax is defined as pleural fluid hematocrit greater than 50% of the peripheral blood hematocrit and the absence of natural or iatrogenic trauma affecting the lung or pleural space.Coagulopathy secondary to anticoagulant use has been associated with spontaneous hemothorax [2,3]. We present a case of spontaneous massive hemothorax in a patient taking apixaban for venous thromboembolism disease. To our knowledge, this is the first case report of apixaban as a cause of spontaneous hemothorax. CASE PRESENTATION: A 56-year-old woman with end-stage renal disease (ESRD) on hemodialysis (HD), diagnosed with upper extremity deep vein thrombosis (DVT) one month prior to presentation and started on apixaban presented with dyspnea and left-sided pleuritic chest pain for two weeks. She was found to have left sided large pleural effusion which was diagnosed as hemothorax after thoracentesis. Other etiologies for spontaneous hemothorax were excluded and drainage by 12-french pigtail catheter achieved total resolution of hemothorax in three days. DISCUSSION: Apixaban is a DOAC used to prevent stroke or thromboembolic events in patients with nonvalvular atrial fibrillation and to prevent recurrent venous thromboembolic disease [7, 8]. Events such as gastrointestinal, intracranial and soft tissue bleedings have been well-documented. However, bleeding manifestation as hemothorax is seldom reported [7]. Our patient presented with isolated left-sided large pleural effusion which was hypoechoic when examined by ultrasound and might be attributed to her being anticoagulated with apixaban. 12-Fr pigtail catheter drainage was effective in the management of our patient and provided total resolution in three days. CONCLUSIONS: Spontaneous hemothorax is a rare complication of anticoagulant therapy and might not exhibit the usual radiological signs of traumatic hemothorax. Health care providers should have high index of suspicion for spontaneous hemothorax when evaluating new pleural effusion in patients receiving DOACs therapy. Drainage by small bore pigtail catheter might be as effective as larger chest tubes without precipitating patient discomfort. Reference #1: 1. Ali HA, Lippmann M, Mundathaje U, Khaleeq G. Spontaneous hemothorax: a comprehensive review. Chest 2008;134:1056–1065 Reference #2: 2. Morecroft JA, Lea RE. Haemothorax: a complication of anticoagulation for suspected pulmonary embolism. Br J Clin Praet 1988; 42:217-218 Reference #3: 3. Diamond MT, Fell SC. Anticoagulant-induced massive hemothorax. NY State J Med 1973; 73:691-692 DISCLOSURES: No relevant relationships by Mohammad Abu Hishmeh, source=Web Response No relevant relationships by Priyasha Srivastava, source=Web Response