Spontaneous Hemorrhagic Pericardial and Pleural Effusion in a Patient Receiving Apixaban

Abstract

Direct oral anticoagulants (DOACs) are used for many conditions where anticoagulation is needed such as non-valvular atrial fibrillation, deep vein thrombosis (DVT) and pulmonary embolism (PE). These novel agents have become popular since they do not require monitoring of therapeutic levels and there is a lower risk of certain bleeding complications when compared to warfarin. However, the efficacy and side effect profile of these agents have not been widely studied in certain patient cohorts, namely cancer patients and patients on immunomodulators or hormone analogs. We present a case of a patient with a history of malignancy and autoimmune disease who developed pericardial and pleural effusions shortly after initiating apixaban for treatment of a PE. In addition, we aim to increase awareness of the role that the newly available reversal agents for anticoagulants would offer in the acute management of hemorrhagic pericardial and pleural effusions caused by DOACs in patients with and without malignancy.

A 73-Year-Old Woman With Pulseless Electrical Activity Arrest

“…Spontaneous hemorrhagic pericardial effusion has been reported previously after the initiation of factor Xa inhibitors. 7,8 In this case, hemorrhagic conversion of uremic pericarditis while undergoing anticoagulation is also a possibility. Although the efficacy of adexanet alfa in the pericardial bleeding subgroup was not specifically reported in the ANNEXA-4 study, subjects with pericardial bleeding were included in this study.…”

Case report of simultaneous presentation of pulmonary embolism and pericardial effusion following an oncological esophagectomy

“…Together this draws suspicion towards Rivaroxaban as the PcE-cause. A case series by Cinelli et al (2019) [ 8 ] presents three cases of direct oral anticoagulant (DOAC)-induced PcE in oncologic patients. All three cases showed malignant cells in fluid cytology, suggesting that this may have played a causative role rather than Rivaroxaban.…”

A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants

“…Atia R et al reported two cases of spontaneous choroidal hemorrhage in patients taking rivaroxaban and dabigatran [32]. Hemorrhagic cardiac tamponade and spontaneous hemopericardium have been reported in patients receiving DOACs [33][34][35]. Jun et al reported three cases of spontaneous vitreous hemorrhage in patients taking rivaroxaban for atrial fibrillation.…”

“…Cullen's sign-the presence of bruising or edema in the abdominal wall-could indicate an underlying intra-abdominal bleed [75]. Intra-thoracic bleed and pulmonary hemorrhage could present as hemothorax and hemoptysis, respectively [35].…”

“…Bleeding complications from direct oral anticoagulant use[10,20,[22][23][24][25][26][27][30][31][32][33][34][35][37][38][39]42].…”