SUPER WARFARIN POISONING AFTER MARIJUANA USE

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Long acting vitamin K antagonists (super warfarins) produce coagulopathy in humans that can last for weeks to months. Exposure to these poisons can be very dangerous, but if recognized early can be effectively treated. CASE PRESENTATION: SW is a 32 year old female with no past medical history who presented to the emergency room due to nausea, vomiting, and abdominal discomfort. Symptoms started suddenly a week prior. Abdominal pain was constant, not associated with food, and was mainly in the upper quadrants with radiation to the flanks. The day of presentation she began to have bright red blood in her emesis as well as gross hematuria. She also noted sudden onset of bruising of her legs bilaterally. Patient was mildly tachycardic with heart rate in the 100s. Initial lab work showed a Hb 14.9 and an INR >29. She stated that she had no allergies, took no medications or herbal supplements, and had no family history of bleeding disorders. She denies any previous history of easy bruising or heavy menses. No previous psychiatric history of depression or suicidality. She denied regular tobacco use and states that she drank alcohol only on rare occasions. She admitted to very rare marijuana use, her last use being a week prior. She had smoked with a friend and this was their first time buying from the specific dealer. She stated the friend was not exhibiting any of the same symptoms. After admission to the ICU she initially received K-Centra which briefly corrected her coagulopathy to an INR 1.1. Over the next 24 hours, however, her INR gradually rose back up to 7.13. After consultation with toxicology the patient was placed on 10mg vitamin K every 8 hours which required escalation to 30mg every 8 hours before the INR remained corrected. An anticoagulant poisoning panel was sent and was positive for brodifacoum and difenacoum. A synthetic cannabinoid panel was run which was negative. She was sent home on this dose of vitamin K with close follow-up scheduled with her PCP. DISCUSSION: Case reports of accidental or intentional exposures to super warfarins have been seen as far back as 1984. They have more recently gained attention due to super warfarins being found mixed with synthetic marijuana. Compared to warfarin, the coagulopathy produced by these agents is more potent and prolonged. Elevated prothrombin time has been reported for weeks to months after ingestion. There is little data on the most optimal treatment algorithm, although case reports have shown large doses of vitamin K are effective for reversing the coagulopathy and maintaining normal INR. CONCLUSIONS: This case shows an occurrence of super warfarin poisoning in conjunction with non-synthetic marijuana use. In cases of significant and prolonged elevation of PT clinicians should keep a low index of suspicion for super warfarin poisoning. Reference #1: Chua JD, Friedenberg WR. Superwarfarin Poisoning. Arch Intern Med. 1998;158(17):1929–1932. https://doi.org/10.1001/archinte.158.17.1929 Reference #2: Long J, Peng X, Luo Y, et al. Treatment of a long-acting anticoagulant rodenticide poisoning cohort with vitamin K1 during the maintenance period. Medicine (Baltimore). 2016;95(51):e5461 DISCLOSURES: No relevant relationships by Jay Patel, source=Web Response No relevant relationships by Rahul Sangani, source=Web Response