Spontaneous splenic hemorrhage in a patient on apixiban

Journal Pre-proof Spontaneous splenic hemorrhage in a patient on apixiban

Alexander Janke, Suzette Ikejiani, Charles Mize PII:

S0735-6757(19)30799-5

DOI:

https://doi.org/10.1016/j.ajem.2019.12.006

Reference:

YAJEM 158634

To appear in:

American Journal of Emergency Medicine

Received date:

21 November 2019

Accepted date:

2 December 2019

Please cite this article as: A. Janke, S. Ikejiani and C. Mize, Spontaneous splenic hemorrhage in a patient on apixiban, American Journal of Emergency Medicine(2019), https://doi.org/10.1016/j.ajem.2019.12.006

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© 2019 Published by Elsevier.

Journal Pre-proof Title: Spontaneous Splenic Hemorrhage in a Patient on Apixiban Alexander Janke1 M.D., Suzette Ikejiani1 M.D., Charles Mize2 M.D. 1

Department of Emergency Medicine, Yale University School of Medicine, 464 Congress, New Haven, CT 06510, USA 2 Department of Emergency Medicine, Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06610, USA

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*Corresponding author: [email protected] Key Words: Resuscitation, NOAC

Journal Pre-proof 1. Introduction

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Novel oral anticoagulants (NOACs) are increasingly popular. Spontaneous splenic rupture is rare and life-threatening, especially if it is not immediately recognized [1, 2]. Organ-specific bleeding patterns among the NOACs include reduced associated intracranial hemorrhage and GI bleed risk relative to warfarin [3]. Splenic rupture is exceeding rare relative to these other bleeding complications. In almost all cases, splenic rupture is associated with an underlying pathologic process (atraumatic-pathologic rupture) rather than atraumatic and idiopathic. Prior work has demonstrated an association with novel oral anticoagulant (NOAC) use and spontaneous splenic rupture in the case of precipitant conditions [4, 5] and in patients with severe underlying chronic disease [6, 7]. While the case of splenic rupture in infectious mononucleosis is well-known, more atypical associations with infections include babesiosis [4] and following IVIg treatment for parvovirus B19-related pure red cell aplasia [8]. In the case of an ectopic pregnancy in the spleen [9], the underlying pathological mechanism is more clear. Among the earliest cases of spontaneous splenic rupture associated with a NOAC, Gonzva et al described an acute presentation of shock in a 67-year old in France who ultimately did well after resuscitation, splenectomy, and a intensive care unit stay complicated by colonic ischemia requiring colectomy [10]

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2. Case description

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We present a case of spontaneous splenic hemorrhage in an otherwise healthy 57-year old female who was recently started on apixiban for a provoked PE. She had been discharged from an outside facility, and presented just hours later to our emergency department in extremis: unconscious, pale, hypotensive, and tachycardic. Her abdomen on arrival was noted to be distended, and bedside ultrasound confirmed massive peritoneal fluid. Prompt diagnostic peritoneal aspirate confirmed hemoperitoneum, and a massive transfusion protocol was initiated. Initial hemoglobin and hematocrit were 4.2 g/dL and 13.4%, platelet count 204,000 per microliter. The patient’s prothrombin time and international normalized ratio were 19.5 seconds and 2.02. The patient received 4 units of packed red blood cells, 1 unit of fresh frozen plasma, prothrombin complex concentrate, and calcium. The patient’s blood pressure, heart rate improved, and mental status improved. Computed tomography demonstrated large subcapsular splenic hematoma with active extravasation at the periphery of the spleen (Figure 1). The patient was taken emergently to interventional radiology suite where splenic artery embolization was performed and an IVC filter was placed. She subsequently developed acute respiratory distress syndrome and persistent low urine output with hypotension despite resuscitation, and was taken to the operating room for splenectomy and abdominal washout. She improved thereafter and was discharged 12 days later. 3. Discussion Prior work has characterized the atraumatic-pathologic splenic rupture in the case of neoplastic (30.3%), infectious (27.3%), inflammatory (20%), iatrogenic (9.2%), and mechanical (6.8%) processes, rarely in the case of a normal spleen (6.4%), and an overall mortality rate of 12.2% [1]. Mortality has been associated with advanced age, underlying neoplastic process, known preceding splenomegaly, and, especially, any delay in diagnosis [2]. With the popularity of the

Journal Pre-proof NAOCs as well as evolving pharmacological strategies at hemorrhage control (fresh frozen plasma, activated prothrombin concentrates, recombinant activated factor VII, idaricizumab), it is essential to recognize this rare but increasingly well-documented issue of atraumatic splenic rupture. Here we present the case of a previously healthy 57-year old, recently anticoagulated for a provoked PE, presenting in shock. Prompt resuscitation with blood products facilitated imaging which clarified her pathology, and splenic artery embolization temporized her until surgical exploration could be performed. 4. Conclusion

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In this patient with spontaneous splenic hemorrhage after recent initiation of apixiban for a provoked PE, prompt diagnosis and aggressive early resuscitation contributed to a favorable outcome.

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Declaration of competing interest

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None

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References

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[1] Renzulli P, Hostettler A, Shoepfer AM, Gloor B, Candinas D. Systematic review of atraumatic splenic rupture. British Journal of Surgery. 2009;96:1114-1121.

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[2] Kocael PC, Simsek P, Bilgin IA, Tutar O, Saribeyoglu K, Pekmezci S, Goksoy E. Characteristics of Patients With Spontaneous Splenic Rupture. Int Surg. 2014;99:714-8.

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[3] Vanassche T, Hirsh J, Eikelboom JW, Ginsberg JS. Organ-specific bleeding patterns of anticoagulant therapy: lessons from clinical trials. Thromb Haemost. 2014;112(5):918-23.

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[4] Khateeb D, Santarelli R, Wexler P, Young D. Hemorrhagic Shock Due To Spontaneous Splenic Rupture: A Rare Complication Of Babesiosis. Crit Car Med. 2019;47(1):300. [5] Niemeyer de Freitas Ribeiro B, Correia RS, Salata TM, Antunes FS, Marchiori E. Subcapsular splenic hematoma and spontaneous hemoperitoneum in a cocaine user. Radiol Bras. 2017;50(2). [6] Amin A, Safaya A, Ronny F, Islam H, Bhuta K et al. Hemorrhagic Shock from Spontaneous Splenic Rupture Requiring Open Splenectomy in a Patient Taking Rivaroxaban. The American Surgeon. 2016;81(2):E54-5. [7] Lowry LE, Goldner JA. Spontaneous splenic rupture associated with apixiban: a case report. J Med Case Reports. 2016;10(217). [8] Tiong M, Casan J, McLean C. Atraumatic splenic rupture following IVIg for parvovirus B19 pur red cell aplasia post renal transplant. Transpl Infect Dis. 2019;21:e13045.

Journal Pre-proof [9] Wu BQ, Zhu F, Jiang Y, Sun DL. Case of spontaneous splenic rupture caused by ectopic pregnancy in the spleen. J Obstet Gynaecol Red. 2017;43(11):1778-80.

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[10] Gonzva J, Patricelli R, Lignac D. Spontaneous splenic rupture in a patient treated with rivaroxaban. Am J Emerg Med. 2014;32(950):e3.

Figure 1