ABSTRACT
Renal vein thrombosis (RVT) is a rare form of deep venous thrombosis. It usually involves one or both renal veins and one of their branches. Most cases were reported in patients with nephrotic syndrome or inherited hypercoagulability syndromes. RVT can present with flank pain, hematuria, and acute kidney injury but can also present asymptomatically and be incidentally discovered on abdominal or renal imaging. The management of RVT is usually with warfarin for at least six to 12 months and periodically is continued if the patient is in the nephrotic range. Direct-acting oral anticoagulants (DOACs) have not been well studied in cases of RVT, especially in patients with coronavirus disease 2019 (COVID-19). We present a case of RVT in the setting of COVID-19 that was treated successfully with a DOAC, rivaroxaban, with complete resolution of the thrombus.
ABSTRACT
Hemorrhagic cardiac tamponade in the setting of direct oral anticoagulants (DOACs) is rare but life-threatening. Presentation in subacute cases can also be nonspecific, which can potentially delay diagnosis. A 60-year-old female with a history of heart failure and chronic obstructive pulmonary disease presented with shortness of breath, chest pain, and cough while on treatment with apixaban after a recent hospitalization for pulmonary embolism. Clinical presentation was consistent with multiple diagnoses, including pneumonia and heart failure exacerbation. However, there were several risk factors for hemopericardium with DOACs such as elevated creatinine, hypertension, elevated international normalized ratio (INR), and concomitant use of medications with similar metabolic pathways as apixaban. In addition, subtle findings on examination such as oximetry paradoxus and electrical alternans were crucial for an early diagnosis and management. In this case, we discuss key characteristics of hemopericardium with DOACs, as well as considerations on its management.
ABSTRACT
Traditionally, the management of patients with pulmonary embolism has been accomplished with anticoagulant treatment with parenteral heparins and oral vitamin K antagonists. Although the administration of heparins and oral vitamin K antagonists still plays a role in pulmonary embolism management, the use of these therapies are limited due to other options now available. This is due to their toxicity profile, clearance limitations, and many interactions with other medications and nutrients. The emergence of direct oral anticoagulation therapies has led to more options now being available to manage pulmonary embolism in inpatient and outpatient settings conveniently. These oral therapeutic options have opened up opportunities for safe and effective pulmonary embolism management, as more evidence and research is now available about reversal agents and monitoring parameters. The evolution of the pharmacological management of pulmonary embolism has provided us with better understanding regarding the selection of anticoagulants. There is also a better understanding and employment of anticoagulants in pulmonary embolism in special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19.