-
Journal of Medical Case Reports Jun 2023Cerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly...
BACKGROUND
Cerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis.
CASE PRESENTATION
We report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2-3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke.
CONCLUSION
Spontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.
Topics: Humans; Middle Aged; Mitral Valve Stenosis; Intracranial Embolism; Heart Valve Diseases; Mitral Valve; Echocardiography; Embolism
PubMed: 37330507
DOI: 10.1186/s13256-023-03982-2 -
Thrombosis Research Aug 2023The European Medicine Agency has authorized COVID-19 vaccination in adolescents and young adults (AYAs) from 12 years onwards. In elderly vitamin K antagonist (VKA)...
INTRODUCTION
The European Medicine Agency has authorized COVID-19 vaccination in adolescents and young adults (AYAs) from 12 years onwards. In elderly vitamin K antagonist (VKA) users, COVID-19 vaccination has been associated with an increased risk of supra- and subtherapeutic INRs. Whether this association is also observed in AYAs using VKA is unknown. Our aim was to describe the stability of anticoagulation after COVID-19 vaccination in AYA VKA users.
MATERIALS AND METHODS
A case-crossover study was performed in a cohort of AYAs (12-30 years) using VKAs. The most recent INR results before vaccination, the reference period, were compared with the most recent INR after the first and, if applicable, second vaccination. Several sensitivity analyses were performed in which we restricted our analysis to stable patients and patients without interacting events.
RESULTS
101 AYAs were included, with a median age [IQR] of 25 [7] years, of whom 51.5 % were male and 68.3 % used acenocoumarol. We observed a decrease of 20.8 % in INRs within range after the first vaccination, due to an increase of 16.8 % in supratherapeutic INRs. These results were verified in our sensitivity analyses. No differences were observed after the second vaccination compared to before and after the first vaccination. Complications after vaccination occurred less often than before vaccination (9.0 vs 3.0 bleedings) and were non-severe.
CONCLUSIONS
the stability of anticoagulation after COVID-19 vaccination was decreased in AYA VKA users. However, the decrease might not be clinically relevant as no increase of complications nor significant dose adjustments were observed.
Topics: Humans; Male; Young Adult; Adolescent; Aged; Adult; Female; COVID-19 Vaccines; Cross-Over Studies; COVID-19; Anticoagulants; International Normalized Ratio; Vitamin K
PubMed: 37321159
DOI: 10.1016/j.thromres.2023.06.005 -
Cureus May 2023Spontaneous hematoma of the iliopsoas is a rare pathological circumstance; in the majority of cases published in the literature, it is associated with disorders of...
Spontaneous hematoma of the iliopsoas is a rare pathological circumstance; in the majority of cases published in the literature, it is associated with disorders of hemostasis due to anticoagulant treatment or coagulopathies. We present a case of a 64-year-old man on acenocoumarol, an anticoagulant of the vitamin K antagonist family, for atrial fibrillation, who presented with a severe left hip and flank pain with a huge ecchymosis on the left flank and a partial inability to extend the left thigh. A CT scan confirmed the diagnosis of iliopsoas hematoma. Given the hemodynamic stability of the patient, he benefited from a conservative treatment with a favourable evolution. This case highlights the underlying conditions, diagnosis, and treatment of this uncommon complication.
PubMed: 37292568
DOI: 10.7759/cureus.38730 -
Indian Journal of Gastroenterology :... Jun 2023Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions...
Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy.
Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.
Topics: Humans; Fibrinolytic Agents; Gastroenterology; Anticoagulants; Gastrointestinal Hemorrhage; Endoscopy, Gastrointestinal; Neurology
PubMed: 37273146
DOI: 10.1007/s12664-022-01324-6 -
Cureus Apr 2023Diffuse alveolar hemorrhage (DAH) is bleeding into the alveolar spaces of the lung. DAH is often associated with systemic autoimmune diseases, coagulation disorders,...
Diffuse alveolar hemorrhage (DAH) is bleeding into the alveolar spaces of the lung. DAH is often associated with systemic autoimmune diseases, coagulation disorders, drugs, inhaled toxins, or transplantation. This study describes a rare case of acenocoumarol-induced DAH, a pulmonary disorder, which has not been reported before. A 48-year-old male presented with a history of rheumatic heart disease with mitral stenosis with moderate mitral regurgitation status post mitral valve replacement. He was taking acenocoumarol but did not keep his prothrombin time-international normalized ratio (PT-INR) monitoring and came to the hospital with complaints of cough, hemoptysis, and breathlessness. Chest x-ray and high-resolution computed tomography (HRCT) thorax were done which revealed diffuse patchy opacities and pulmonary hemorrhage, respectively. After nine days of hospital stay with appropriate management with corticosteroids, antibiotics, and intravenous fluids, the patient was doing well.
PubMed: 37193442
DOI: 10.7759/cureus.37581 -
Cureus Apr 2023A common complication of anticoagulation therapy is bleeding, especially in patients receiving long-term vitamin K antagonists. Spontaneous intramural hematoma is a rare...
A common complication of anticoagulation therapy is bleeding, especially in patients receiving long-term vitamin K antagonists. Spontaneous intramural hematoma is a rare etiology among life-threatening major bleeds. An 80-year-old female patient presented with diffuse abdominal pain. Her history included ischemic heart disease and chronic atrial fibrillation treated with 3 mg of acenocoumarol per day. Three days before her admission, she developed diffuse abdominal pain with fecaloid vomiting, bloating, and not passing gas. Palpation of the abdomen revealed asymmetrical distension and pain, with no signs of peritoneal irritation or bleeding. Investigations showed anemia with a hemoglobin level of 9.2 g/dL, a white blood cell count of 14200/mm, a C-reactive protein of 112.6 mg/L, and a prothrombin time of 75.1 seconds with an international normalized ratio (INR) of 8.5. Abdominal contrast-enhanced computed tomography (CT) showed segmental parietal thickening, luminal narrowing, and partial small bowel obstruction secondary to an intramural jejunum hematoma responsible for a gallbladder occlusion with infiltration of the mesenteric fat in front. The patient recovered two days after conservative treatment. In this case, we report an unusual small bowel intramural hematoma of the jejunum secondary to anticoagulant therapy. Physicians should be aware of this unusual cause of abdominal pain. Early diagnosis may avoid unnecessary surgical exploration.
PubMed: 37162778
DOI: 10.7759/cureus.37257 -
Cureus Mar 2023Coumarin derivatives are the most used class of oral anticoagulants, and almost 1-2% of adults worldwide take it in the form of warfarin (WA) or acenocoumarol (AC)....
Coumarin derivatives are the most used class of oral anticoagulants, and almost 1-2% of adults worldwide take it in the form of warfarin (WA) or acenocoumarol (AC). Cutaneous necrosis is a rare and severe complication of oral anticoagulant therapy. Most commonly, it occurs in the first 10 days, and the incidence peaks between the third and sixth day of starting treatment. Cutaneous necrosis due to AC therapy is underreported in the literature, and studies refer to this condition as "coumarin-induced skin necrosis"; however, this term is not totally accurate, as coumarin itself has no anticoagulant properties. We report a case of a 78-year-old female patient with AC-induced skin necrosis, who presented with cutaneous ecchymosis purpura over her face, arms, and lower extremities 3 hours after AC intake.
PubMed: 37131576
DOI: 10.7759/cureus.36960 -
Cureus Mar 2023Spontaneous renal rupture (SRR) with retroperitoneal hemorrhage is an extremely rare medical emergency and is rather challenging for the surgical team. Management of SRR...
Spontaneous renal rupture (SRR) with retroperitoneal hemorrhage is an extremely rare medical emergency and is rather challenging for the surgical team. Management of SRR often requires surgical intervention and nephrectomy as it is life-threatening. Antiphospholipid syndrome (APLS) is an autoimmune disease that affects several organs, including kidneys, causing significant abnormalities. Current data suggest that APLS can result in renal artery stenosis, renal vein thrombosis, arterial hypertension, thrombotic microangiopathy, and antiphospholipid syndrome nephropathy where there is renal involvement. Here, we report the case of a 49-year-old man who presented to the Emergency Department with sudden-onset abdominal pain in the context of retroperitoneal bleeding due to SRR. The patient developed hemodynamic instability and underwent a total nephrectomy. The surgical specimen revealed APLS-related lesions. Serological tests confirmed the diagnosis of APLS, which was managed with acenocoumarol and hydroxychloroquine. Since then, he has not experienced any thromboembolic or hemorrhagic episodes. This article aims to present for the first time a case of SRR as the first presentation of APLS as well as to analyze the possible associated mechanisms.
PubMed: 37123758
DOI: 10.7759/cureus.36839 -
Pharmaceuticals (Basel, Switzerland) Apr 2023Hyperpigmentation can occur in abnormal skin conditions such as melanomas, as well as in conditions including melasma, freckles, age spots, seborrheic keratosis, and...
Hyperpigmentation can occur in abnormal skin conditions such as melanomas, as well as in conditions including melasma, freckles, age spots, seborrheic keratosis, and café-au-lait spots (flat brown spots). Thus, there is an increasing need for the development of depigmenting agents. We aimed to repurpose an anticoagulant drug as an effective ingredient against hyperpigmentation and apply cosmeceutical agents. In the present study, the anti-melanogenic effects of two anticoagulant drugs, acenocoumarol and warfarin, were investigated. The results showed that both acenocoumarol and warfarin did not cause any cytotoxicity and resulted in a significant reduction in intracellular tyrosinase activity and melanin content in B16F10 melanoma cells. Additionally, acenocoumarol inhibits the expression of melanogenic enzymes such as tyrosinase, tyrosinase-related protein (TRP)-1, and TRP-2, suppressing melanin synthesis through a cAMP-dependent, protein kinase (PKA)-dependent downregulation of microphthalmia-associated transcription factor (MITF), a master transcription factor in melanogenesis. Furthermore, anti-melanogenic effects were exerted by acenocoumarol through downregulation of the p38 and JNK signaling pathway and upregulation of extracellular signal-regulated kinase (ERK) and phosphatidylinositol 3 kinase (PI3K)/protein kinase B (Akt)/glycogen synthesis kinase-3β (GSK-3β) cascades. In addition, the β-catenin content in the cell cytoplasm and nucleus was increased by acenocoumarol through a reduction in the phosphorylated β-catenin (p-β-catenin content). Finally, we tested the potential of acenocoumarol for topical applications by conducting primary human skin irritation tests. Acenocoumarol did not induce any adverse reactions during these tests. Based on the results, it can be concluded that acenocoumarol regulates melanogenesis through various signaling pathways such as PKA, MAPKs, PI3K/Akt/GSK-3β, and β-catenin. These findings suggest that acenocoumarol has the potential to be repurposed as a drug for treating hyperpigmentation symptoms and could provide new insights into the development of therapeutic approaches for hyperpigmentation disorders.
PubMed: 37111361
DOI: 10.3390/ph16040604 -
Cureus Mar 2023Coronavirus disease 2019 (COVID-19) causes endothelial damage, blood stasis, and an overall state of hypercoagulability. This makes COVID a huge risk factor for venous... (Review)
Review
Coronavirus disease 2019 (COVID-19) causes endothelial damage, blood stasis, and an overall state of hypercoagulability. This makes COVID a huge risk factor for venous thromboembolism (VTE) and arterial thromboembolism (ATE). Twenty percent of COVID-19 patients suffer from coagulation abnormalities like pulmonary embolism, myocardial infarction, stroke, deep vein thrombosis, etc. Ovarian vein thrombosis (OVT) has been previously linked to post-partum period, pregnancy, hypercoagulable state, or malignancy. We analyzed PubMed and Google Scholar databases for research and publications regarding OVT in patients with COVID-19. The search yielded nine case reports. These case reports were found to implicate COVID-associated coagulopathy (CAC) as an additional risk factor for ovarian vein thrombosis (OVT). OVT most commonly presents with abdominal pain and fever, making it difficult to diagnose, owing to the similarity in presentation with multiple other pathologies. OVT can be diagnosed radiologically with ultrasound, magnetic resonance imaging (MRI) scan, or CT scan with IV contrast. CT has been used as the modality of choice for diagnosing OVT. Although rare, OVT can cause life-endangering complications by extension of thrombus into systemic veins or pulmonary artery embolization. Therefore, early diagnosis and treatment are vital. There is no official guideline for the treatment of OVT post-COVID. However, the literature supports the use of apixaban or enoxaparin/acenocoumarol.
PubMed: 37090373
DOI: 10.7759/cureus.36437