bromfenacoum and Blood-Coagulation-Disorders

Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or "fake weed" highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management.

Topics: 4-Hydroxycoumarins; Anticoagulants; Blood Coagulation Disorders; Cannabinoids; Disease Management; Drug Contamination; Humans

Rodenticide (RD) application is the most effective chemical procedure against rodents. RDs containing indirect-action anticoagulants have received currently wide acceptance. When the recommended standards for handling these agents and precautionary measures in their use are violated, there may be poisoning, the main manifestation of which is hemorrhagic coagulation. The paper provides a literature review on poisoning by RDs having anticoagulant properties. This communication gives a detailed description of a clinical case of poisoning with brodifacoum contained in the ready-to-use Nutcracker bait due to long-term exposure to the rat poison that has a cumulative effect. Careful history data collection and coagulogram analysis make it possible to establish a correct clinical diagnosis and to use appropriate therapy that leads to patient recovery.

Topics: 4-Hydroxycoumarins; Adult; Animals; Anticoagulants; Blood Coagulation Disorders; Female; Hemorrhage; Humans; Male; Middle Aged; Rats; Rodenticides

Superwarfarins are anticoagulant rodenticides similar to warfarin, but which have various substituted phenyl groups replacing the terminal methyl group, resulting in a fat-soluble, long-acting anticoagulant that is nearly 100 times more potent than the parent compound. Since their development, many accidental and intentional cases of consumption have been reported. We describe two cases of consumption, one related to unknown etiology, and the other related to utilization of the superwarfarin to potentiate a drug of abuse. The clinical manifestations including bleeding symptoms and abnormal coagulation assays are discussed. The differential diagnosis is quite broad, and includes all causes of vitamin K deficiency, factor deficiency or inhibitor, disseminated intravascular coagulation (DIC), and liver disease. Differentiating superwarfarin ingestion from the other causes can be quite difficult, but extremely important, as management requires prolonged administration of vitamin K. Other treatment options are discussed as well including, fresh frozen plasma (FFP), and recombinant factor VIIa. Finally, the significance of "lacing" drugs of abuse with superwarfarin to potentiate their effect is discussed, as well as the complications that could develop from such a habit.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Diagnosis, Differential; Humans; Male; Middle Aged; Pain; Platelet Count; Prothrombin Time; Thromboplastin; Time Factors; Vitamin K Deficiency

Superwarfarins are found in many pesticides, including D-con, Prufe I and II, Ramik, Talon-G, Ratak, and Contrac. Ingestion of can lead to significant morbidity and even mortality. Physicians need to consider this diagnosis in any patient presenting with coagulopathy of unclear etiology. We present a patient with superwarfarin-induced coagulopathy and review previous cases in adults in the literature. The patient is a 60-year-old man who presented to our medical center with painless hematuria. Laboratory studies revealed an elevated prothrombin time (PT) (42.5 seconds), partial thromboplastin time (PTT) (64.6 seconds), and international normalized ratio (INR) of 7. Liver-associated enzymes were normal, and complete blood cell count (CBC) showed no evidence of disseminated intravascular coagulation. Subsequent work-up included the absence of an inhibitor by mixing study and deficiencies of vitamin K-dependent coagulation factors. The patient's warfarin level was negative. A brodifacoum level was positive, confirming superwarfarin-induced coagulopathy. The patient is currently doing well with normal coagulation studies after receiving high doses of vitamin K for several weeks. The cause of his exposure to superwarfarin remains uncertain. Physicians need to be cognizant of this unusual cause of coagulopathy in adults. The appropriate diagnostic work-up and unique features of therapy are discussed.

Topics: 4-Hydroxycoumarins; Blood Coagulation Disorders; Humans; Male; Middle Aged

We report the deliberate ingestion of a superwarfarin product, brodifacoum, in a 39-y-old male. He presented with prothrombin and partial thromboplastin times of 150 and 113 sec, respectively. His coagulopathy was corrected by administration of blood products and phytonadione. To maintain normal clotting studies this patient required the highest maintenance dose of phytonadione, 200 mg/d, reported to date. The patient was able to tolerate this dose for 5 mo without adverse effects.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Chronic Disease; Humans; Male; Partial Thromboplastin Time; Prothrombin Time; Rodenticides; Suicide, Attempted; Vitamin K 1

The increased prevalence of rodents resistant to warfarin led to the development of the hydroxycoumarin anticoagulant brodifacoum. A 25-year-old man attempted suicide by consuming four boxes of d-CON Mouse-Prufe II; each box contains 42 g of bait that is 0.005% brodifacoum. He presented to a hospital nine days later with syncope, hematochezia, gross hematuria, epistaxis, anemia, and a severe coagulopathy. Radiographic studies were consistent with pleural, pericardial, and mediastinal hemorrhages. Vitamin K and fresh frozen plasma were given, and he was later discharged on oral phytonadione (vitamin K1). The patient's coagulopathy recurred, necessitating multiple plasma transfusions and prolonged treatment with oral phytonadione. Fifteen weeks after hospital discharge, he presented again with a history of additional brodifacoum ingestion. Neurologic status was initially normal, but in the emergency department he suddenly became comatose soon after emesis was induced with syrup of ipecac. Computed tomography of the brain revealed a subarachnoid hemorrhage that led to brain death less than 24 hours later. This case demonstrates the severe and prolonged coagulopathy that can result from ingestion of brodifacoum, a compound that has a toxic potency about 200-fold that of warfarin and a half-life as much as 60 times longer.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Blood Transfusion; Drug Overdose; Emergency Service, Hospital; Humans; Ipecac; Male; Partial Thromboplastin Time; Patient Readmission; Phenobarbital; Plasma; Poisoning; Prothrombin Time; Rodenticides; Subarachnoid Hemorrhage; Suicide; Tomography, X-Ray Computed; Vitamin K

Superwarfarin (long-acting anticoagulant rodenticide) poisoning should be suspected in unexplained bleeding with prolonged prothrombin time, especially in the absence of another explanation. Diagnosis and treatment of this intoxication remain a challenge as the direct analysis of superwarfarin in serum is not always possible. Therefore, toxin bioavailability remains unknown and close monitoring and treatment for long periods are required to avoid serious bleeding complications. Here, we discuss a case of suspected superwarfarin poisoning to highlight the challenges in early diagnosis and the challenges we encountered in treatment management and ensuring compliance for long periods.

Topics: 4-Hydroxycoumarins; Anticoagulants; Blood Coagulation Disorders; Humans; Poisoning; Rodenticides

Topics: 4-Hydroxycoumarins; Blood Coagulation Disorders; Florida; Humans; Poisoning

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Cannabinoids; Drug Contamination; Female; Humans; Rodenticides

Synthetic cannabinoids contain many different chemicals and compounds, which pose new health risks to the population using these drugs. In May of 2018 the Center for Disease Control issued a health alert providing information on a multistate outbreak of coagulopathy from exposure to synthetic cannabinoid products containing a Vitamin K-dependent antagonistic agent such as brodifacoum. Recognizing signs, symptoms and imaging findings related to this outbreak is essential for clinicians caring for patients with a history or suspicion of using synthetic cannabinoids. To our knowledge, there are no studies that report the imaging findings demonstrating the coagulopathic complications associated with these synthetic compounds.

Topics: 4-Hydroxycoumarins; Blood Coagulation Disorders; Cannabinoids; Designer Drugs; Emergency Service, Hospital; Fatal Outcome; Hemorrhage; Humans; Male; Middle Aged; Tomography, X-Ray Computed; Vitamin K

A large-scale outbreak of life-threatening, inhaled synthetic cannabinoids (Spice/K2)-associated coagulopathy with bleeding complications was recently reported in Illinois. The causative agents were brodifacoum, difenacoum, and bromadiolone, potent, long-acting, 4-hydroxycoumarin anticoagulant rodenticides (LAAR) that were mixed with Spice/K2 products procured and then inhaled by the victims. We report on 3 poisoned patients who reside in underserved, socioeconomically disadvantaged neighborhoods of Chicago that were admitted and treated successfully at two inner-city, tertiary care hospitals in Chicago. The patients were discharged from the hospitals on daily long-term high-dose oral vitamin K

Topics: 4-Hydroxycoumarins; Administration, Inhalation; Adult; Aftercare; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Disorders; Cannabinoids; Chicago; Female; Hemorrhage; Humans; International Normalized Ratio; Lost to Follow-Up; Male; Medication Adherence; Middle Aged; Patient Compliance; Synthetic Drugs; Vitamin K 1

Warfarin- and superwarfarin-type anticoagulants are commonly used as rodenticides. Exposure to these agents, especially superwarfarins with long-acting anticoagulant effect, can cause life-threatening coagulopathy in humans. Most superwarfarin poisoning cases had an obvious history of exposure, though occult cases without exposure history have also been reported. The current study aims to examine anticoagulant-type rodenticide poisoning in Hong Kong and to identify the similarities and differences between patients with known exposure history and those whose exposure is recognized only through laboratory testing.. The present study was conducted in a tertiary referral clinical toxicology laboratory in Hong Kong. This was a retrospective cohort study of all patients with biochemically confirmed anticoagulant-type rodenticide exposure, from 2010 to 2014.. Superwarfarin was the most common group of anticoagulant-type rodenticides identified (87.8%), in which bromadiolone and brodifacoum were the most frequently encountered. Among the 41 cases identified, 31 had an obvious exposure history, and 10 were occult poisoning in which the context of exposure remained unidentified. All occult poisoning patients without exposure history presented with bleeding events. These occult poisoning cases often went unrecognized by frontline clinicians, leading to delayed investigation and initiation of treatment. This group of patients was associated with a longer time to diagnose coagulopathy (p < 0.001) and confirm rodenticide poisoning (p < 0.05), a higher rate of international normalized ratio (INR) rebound after initiation of antidote (p < 0.001), and a longer time needed for normalizing INR (p < 0.05).. Occult superwarfarin poisoning is an important yet under-recognized differential cause of unexplained coagulopathy. A high index of clinical suspicion and availability of specialized toxicological test for superwarfarins play a vital role in diagnosis and early initiation of appropriate management. The underlying cause of such poisoning remains obscure and warrants further study.

Topics: 4-Hydroxycoumarins; Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Disorders; Cohort Studies; Female; Hemorrhage; Hong Kong; Humans; Infant; International Normalized Ratio; Male; Middle Aged; Poisoning; Retrospective Studies; Rodenticides; Vitamin K; Warfarin; Young Adult

Topics: 4-Hydroxycoumarins; Adolescent; Adult; Aged; Blood Coagulation Disorders; Cannabinoids; Disease Outbreaks; Female; Humans; Illinois; Male; Middle Aged; Severity of Illness Index; Synthetic Drugs; Young Adult

Topics: 4-Hydroxycoumarins; Adult; Anticoagulants; Blood Coagulation Disorders; Humans; Illinois; Male; Marijuana Use; Synthetic Drugs

Acute, unintentional drug-related poisonings lead to an estimated 418,313 ED visits in 2014, according to the latest statistics from the Center for Disease Control and Prevention. While most of these were opiate-related poisonings, anticoagulant rodenticides were the most common cause of rodenticide-related poisoning in the United States. Many clinical syndromes and treatment algorithms have been described for patients with anticoagulant rodenticide poisoning. We report a case of an acute ingestion of two anticoagulant rodenticides and successful reversal of coagulation parameters using 4-factor prothrombin complex concentrate in a fixed-dose approach.

Topics: 4-Hydroxycoumarins; Abdominal Pain; Aged; Anticoagulants; Blood Coagulation Disorders; Blood Coagulation Factors; Drug Contamination; Drug Dosage Calculations; Hemorrhage; Humans; Illicit Drugs; Male; Rodenticides; Synthetic Drugs; Treatment Outcome; Vitamin K

Synthetic marijuana is a dangerous substance due to its potency, ever-changing composition, and unpredictable side effects. Recently, brodifacoum-contaminated synthetic marijuana has led to multiple deaths and morbidity throughout the USA from severe coagulopathy associated with use of this strain of the drug (brodifacoum is a rodenticide and potent Vitamin K antagonist/anticoagulant). We describe the clinical and radiologic findings in two patients who were diagnosed with, and treated for, ingestion of this new strain of synthetic marijuana. The radiologic manifestations were most notable for hemorrhagic pyelitis/ureteritis. Both patients required hospitalization with Vitamin K supplementation. The radiologic and clinical pictures in these patients are important for radiologists to recognize in order to help guide appropriate patient management.

Topics: 4-Hydroxycoumarins; Adult; Baltimore; Blood Coagulation Disorders; Cannabinoids; Diagnosis, Differential; Disease Outbreaks; Female; Humans; Illicit Drugs; Male; Middle Aged; Poisoning; Rodenticides; Tomography, X-Ray Computed; Vitamin K

In March and April 2018, more than 150 patients presented to hospitals in Illinois with coagulopathy and bleeding diathesis. Area physicians and public health organizations identified an association between coagulopathy and synthetic cannabinoid use. Preliminary tests of patient serum samples and drug samples revealed that brodifacoum, an anticoagulant, was the likely adulterant.. We reviewed physician-reported data from patients admitted to Saint Francis Medical Center in Peoria, Illinois, between March 28 and April 21, 2018, and included in a case series adult patients who met the criteria used to diagnose synthetic cannabinoid-associated coagulopathy. A confirmatory anticoagulant poisoning panel was ordered at the discretion of the treating physician.. A total of 34 patients were identified as having synthetic cannabinoid-associated coagulopathy during 45 hospitalizations. Confirmatory anticoagulant testing was performed in 15 of the 34 patients, and superwarfarin poisoning was confirmed in the 15 patients tested. Anticoagulant tests were positive for brodifacoum in 15 patients (100%), difenacoum in 5 (33%), bromadiolone in 2 (13%), and warfarin in 1 (7%). Common symptoms at presentation included gross hematuria in 19 patients (56%) and abdominal pain in 16 (47%). Computed tomography was performed to evaluate abdominal pain and revealed renal abnormalities in 12 patients. Vitamin K. Our data indicate that superwarfarin adulterants of synthetic cannabinoids can lead to clinically significant coagulopathy. In our series, in most of the cases in which the patient presented with bleeding diathesis, symptoms were controlled with the use of vitamin K

Topics: 4-Hydroxycoumarins; Abdominal Pain; Adult; Anticoagulants; Blood Coagulation Disorders; Blood Transfusion; Cannabinoids; Female; Hematuria; Hemorrhage; Humans; Illinois; International Normalized Ratio; Male; Middle Aged; Patient Readmission; Vitamin K; Warfarin

Topics: 4-Hydroxycoumarins; Blood Coagulation Disorders; Dissociative Disorders; Eating; Female; Follow-Up Studies; Humans; Middle Aged; Risk Assessment; Suicide, Attempted; Vitamin K

Topics: 4-Hydroxycoumarins; Anticoagulants; Blood Coagulation Disorders; Blood Coagulation Factors; Health Care Costs; Humans; Risk Factors; Time Factors; United States

A case of brodifacoum exposure leading to coagulopathy lasting for approximately one year despite treatment with large doses of phytonadione is reported.. A 36-year-old man was diagnosed with severe coagulopathy. He was treated and discharged on 40 mg of oral phytonadione daily. The cause of the coagulopathy remained unknown at discharge, but the hematologist theorized that exposure to a vitamin K antagonist was likely the source of the patient's condition. The patient was rehospitalized one week later with an International Normalized Ratio (INR) of 5.9 despite self-reported medication compliance. Oral phytonadione was increased to 80 mg daily. The patient was seen at an outpatient hematology clinic for several months and continued on tapering dosages of oral phytonadione. A coagulopathy panel from the original hospitalization confirmed the presence of brodifacoum, though the method of exposure remained unclear. He was lost to follow-up until approximately nine months later, when he reported taking 10 mg daily of oral phytonadione and had an INR of 1. Oral phytonadione was discontinued. Two months later, his INR was greater than 9, despite an undetectable level of brodifacoum. He was rehospitalized with oropharyngeal hematoma approximately 1 year after the initial coagulopathy diagnosis. The patient was discharged on 40 mg oral phytonadione daily with outpatient follow-up.. A patient with brodifacoum exposure ingested brodifacoum had coagulopathy that lasted approximately one year despite long-term treatment with large dosages of oral phytonadione. The coagulopathy persisted even when brodifacoum was undetectable in the serum. Long-term treatment with high-dose phytonadione is expensive, which may influence medication compliance.

Topics: 4-Hydroxycoumarins; Adult; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Disorders; Follow-Up Studies; Humans; International Normalized Ratio; Male; Rodenticides; Severity of Illness Index; Time Factors; Vitamin K 1

Brodifacoum, a superwarfarin, is a common household agent used for rodenticides. We present a case of maternal brodifacoum ingestion that resulted in neonatal death.. A 19-year-old primigravid woman presented at 32 weeks of gestation with spontaneous mucosal bleeding. Her fetus showed evidence of acidosis on external fetal monitoring. Laboratory values were consistent with maternal coagulopathy. After correction of the coagulopathy, the patient was taken for urgent cesarean delivery. The neonate showed evidence of fetal coagulopathy and died at 4 days of life.. Brodifacoum is a dangerous household chemical that, if ingested, can result in significant morbidity and mortality for both mother and neonate. Increased awareness of the serious and potentially lethal effects of brodifacoum is important.

Topics: 4-Hydroxycoumarins; Adult; Anticoagulants; Blood Coagulation Disorders; Fatal Outcome; Female; Humans; Infant, Newborn; Infant, Newborn, Diseases; Maternal-Fetal Exchange; Pregnancy; Prenatal Exposure Delayed Effects; Rodenticides; Young Adult

Superwarfarins (brodifacoum, difenacoum, bromodialone and chlorphacinone) are anticoagulant rodenticides that were developed in 1970s to overcome resistance to warfarin in rats. A 26-year-old previously healthy man was admitted to the emergency department with epigastric pain, severe upper and lower gastrointestinal haemorrhage, gingival bleeding and melena. The patient stated that he had been healthy with no prior hospital admissions and no personal or family history of bleeding diathesis. The patient, who later admitted attempted suicide, stated that he had taken 400 g rodenticide including brodifacoum orally for five days prior to admission to hospital. He had oral mucosal bleeding, numerous bruises over the arms, legs and abdomen, and an abdominal tenderness, together with melena. Laboratory tests revealed a haemoglobin level of 12.3 g/dl, leucocyte count of 9.1 × 10(9) /l, haematocrit of 28% and platelet count of 280 × 10(9) /l. The prothrombin time (PT) was > 200 s (normal range 10.5-15.2 s) and the activated partial thromboplastin time (aPTT) was 91 s (normal range 20-45 s). The INR (International normalised ratio) was reported to be > 17 (normal range 0.8-1.2). The thrombin time and plasma fibrinogen levels were in the normal range. The results showed the presence of brodifacoum at a concentration of 61 ng/ml, detected by reversed-phase liquid chromatography.

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; 4-Hydroxycoumarins; Adult; Animals; Anti-Ulcer Agents; Anticoagulants; Blood Coagulation Disorders; Emergency Service, Hospital; Gastrointestinal Hemorrhage; Humans; Male; Pantoprazole; Partial Thromboplastin Time; Poisoning; Prothrombin; Rats; Rodenticides; Suicide, Attempted; Treatment Outcome; Vitamin K

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Female; Humans; Munchausen Syndrome; Pulmonary Embolism; Rodenticides

A female patient with significant coagulopathy is presented for case discussion. This case represented a presumed Munchausen exposure to commercially available rat poison that contained one of the superwarfarin chemicals, brodifacoum. Review of the medical literature is undertaken to discuss the diagnostic approach and treatment of superwarfarin exposure. The accidental or intentional exposure to this group of rodenticide represents a significant public health problem that often is not considered by primary care physicians when confronted with coagulopathy.

Topics: 4-Hydroxycoumarins; Animals; Anticoagulants; Blood Coagulation Disorders; Blood Coagulation Tests; Female; Humans; Middle Aged; Munchausen Syndrome; Rats; Rodenticides; Vitamin K

Brodifacoum, also known as a superwarfarin, is a four-hydroxycoumarin derivative. It exerts an anticoagulant effect by inhibiting the reduction of vitamin K-2,3 epoxide, thereby decreasing the production of vitamin K-dependent clotting factors. It is a readily available rodenticide that has been associated with accidental ingestions in children. We report the case of a 21-year-old male who was admitted to the hospital with spontaneous bruising, hematuria and abdominal pain secondary to a perinephric hematoma. The patient was found to have a markedly prolonged prothrombin time and activated partial thromboplastin time that corrected with mixing of normal plasma. He had a normal factor V level; however, factors VII and X were less than 1% and factors II and IX were between 2% and 4% of normal. Ingestion of an anticoagulant was suspected, although the patient denied intentional or accidental ingestion. He was treated with FEIBA (Factor VIII Inhibitor Bypass Activity), fresh frozen plasma and oral vitamin K. The patient was stabilized and discharged from the hospital on oral vitamin K 50 mg twice daily. A serum brodifacoum level was later found to be markedly elevated at 320 ng/ml. We followed the brodifacoum level, which decreased to 31 ng/ml approximately six weeks after initial presentation. The exact length of treatment required to prevent recurrence of the coagulopathy was not determined because the patient did not return for follow-up. Superwarfarin ingestion must be suspected and quickly identified in patients with depletion of vitamin K-dependent clotting factors resulting in potentially catastrophic bleeding.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Blood Coagulation Factors; Humans; Male; Plasma; Rodenticides; Treatment Outcome; Vitamin K; Vitamin K Deficiency

A 23-year-old man was brought to the emergency department after eating four boxes of brodifacoum-containing rodenticide over a 4-day interval and pieces from approximately two bottles of glass over the previous 2 weeks. He was asymptomatic but his prothrombin time was markedly elevated with an international normalized ratio (INR) of 37.8. A plain abdominal film showed diffuse radiopaque foreign bodies, presumably glass, in the large and distal small intestines. Treatment for ingested glass consisted of stool softeners and bulk-forming laxatives. The patient developed mild gingival bleeding and received fresh frozen plasma (FFP) infusions and vitamin K1 orally. At a vitamin K1 dosage of 300 mg/day, the INR corrected to less than 2.0 and the patient was discharged taking that dosage. He returned 26 days later with hematuria and flank pain, and his INR was 189. He was administered FFP and packed red blood cells, and his vitamin K1 dosage was increased to 800 mg/day; his INR returned to baseline. Compliance with taking the vitamin K1, which required ingestion of 60-160 tablets/day, was a serious problem, requiring numerous follow-up calls and visits to the patient at home and work. At 5-month follow he was doing well. Compliance with large daily doses of vitamin K1 for treatment of "superwarfarin" ingestion may be poor because of the duration of treatment and large number of pills required. A more concentrated formulation may be advantageous for management of patients with brodifacoum poisoning.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Deglutition; Drug Packaging; Glass; Humans; International Normalized Ratio; Male; Patient Compliance; Rodenticides; Vitamin K 1

A 35-year-old woman was admitted to hospital because of epistaxis, hematomas, and metrorrhagia. Laboratory data indicated severe coagulopathy with prolonged prothrombin time and decreased serum concentrations of vitamin K-dependent clotting factors II, VII, IX, and X. The patient denied taking any oral anticoagulants. She was given transfusions of red blood cells, fresh frozen plasma (1,180 mL) and phytomenadione daily for 6 weeks (total dose 550 mg), which normalized the coagulation factors concentration. After all other possible causes of acquired coagulopathy had been excluded, rodenticide poisoning was suspected on the basis of her epidemiologic history. The patient was a war refugee from Bosnia and Herzegovina. During her absence, the troops of United Nations Protection Force performed rodent extermination in and around her house. History data and therapeutic effects suggested that the coagulopathy had been caused by prolonged exposure to long-acting anticoagulant rodenticide. This could also explain the need for protracted phytomenadione therapy.

Topics: 4-Hydroxycoumarins; Adult; Anticoagulants; Blood Coagulation Disorders; Female; Humans; Pregnancy; Rodenticides

Brodifacoum is the major rodenticide used in the United States today. It is similar to warfarin but has more potent and prolonged effects. Large overdoses and chronic intoxication have been associated with significant coagulopathies and death. Currently, the management of acute unintentional ingestions by young children is controversial.. American Association of Poison Control Centers (AAPCC) data from 1993 to 1996 were retrospectively searched for acute, unintentional brodifacoum exposures without coingestions followed-up to a known outcome in children aged 6 years and younger. The cases were analyzed by management site, symptoms, therapy, and outcome. Cases coded as having clinical or laboratory evidence of coagulopathy were further evaluated for severity.. Our study reviewed 10,762 cases that involved single, acute, unintentional ingestions of brodifacoum. All of the patients were followed-up to a known outcome as defined by AAPCC data collection standards. In this cohort, there were no deaths or major effects reported. Although 67 patients reported evidence of coagulopathy, no major effects or deaths were reported. Minor and moderate effects were reported in 38 and 54 children, respectively. Management occurred outside of a healthcare facility in 5404 (50.2 %) cases. Approximately half of all the children received some form of gastrointestinal decontamination. Decontamination had no effect on the distribution of outcomes. Adverse effects from decontamination therapy were reported in 42 patients.. Acute pediatric ingestions of brodifacoum rarely caused clinical effects and were not associated with life-threatening symptoms or death in young children. It seems reasonable that acute unintentional ingestions of small quantities of brodifacoum by young children can be adequately managed with home observation and parent education.

Topics: 4-Hydroxycoumarins; Acute Disease; Blood Coagulation Disorders; Child; Female; Humans; Infant; Male; Poisoning; Prothrombin Time; Retrospective Studies; Rodenticides; United States

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Blood Coagulation Factors; Crack Cocaine; Drug Synergism; Epistaxis; Hemorrhage; Humans; Male; Retroperitoneal Space; Rodenticides

Hemorrhage resulting from ingestion of anticoagulant rodenticides may be evident at any traumatized site or in any body cavity. It is important for clinicians to include coagulopathies among the differential diagnoses for pericardial effusion and to evaluate clotting function before routine pericardiocentesis is performed.

Topics: 4-Hydroxycoumarins; Animals; Anti-Arrhythmia Agents; Blood Coagulation Disorders; Blood Transfusion; Cardiac Tamponade; Diagnosis, Differential; Dog Diseases; Dogs; Electrocardiography; Female; Lidocaine; Partial Thromboplastin Time; Pericardial Effusion; Quinidine; Radiography, Thoracic; Rodenticides; Vitamin K 1

Superwarfarin sodium exposure or poisoning is a growing public health problem. There were 5133 reported cases of superwarfarin exposure and poisoning in 1988 and 13 423 cases in 1995. Cases may be associated with accidental exposure, suicide attempts, or Munchausen syndrome, and may be difficult to diagnose.. Patients from northern Wisconsin with superwarfarin exposure or poisoning were examined at a tertiary referral center in rural Wisconsin to determine what led to their exposure and to review the clinical manifestations, diagnosis, treatment, and prevention of superwarfarin poisoning.. Eleven cases satisfied the criteria for superwarfarin exposure or poisoning. All 7 children included in the study had accidentally ingested superwarfarin, 2 adults had Munchausen syndrome, and 1 teenager and 1 adult had attempted suicide using superwarfarin. Nine of the 11 cases had taken brodifacoum. The patients who had accidentally ingested superwarfarin or attempted suicide using it were easily diagnosed, while diagnosis was markedly delayed for the 2 patients with Munchausen syndrome. Full reversal of anticoagulation was quickly achieved in the cases of accidental ingestion and attempted suicide. We examined and treated the patients with Munchausen syndrome for months before establishing a diagnosis and fully reversing the anticoagulation. None of the patients in our study died of superwarfarin poisoning.. Superwarfarin exposure or poisoning is a growing public health problem that should be part of the differential diagnosis of patients who present with a coagulopathy consistent with vitamin K deficiency in the absence of coumadin therapy, liver disease, or the use of an inhibitor, and whose conditions do not resolve with large doses of parenteral vitamin K1 therapy.

Topics: 4-Hydroxycoumarins; Adult; Aged; Anticoagulants; Blood Coagulation Disorders; Diagnosis, Differential; Female; Humans; Incidence; Male; Middle Aged; Munchausen Syndrome; Poisoning; Rodenticides; Suicide, Attempted; United States; Vitamin K; Wisconsin

An elderly Chinese was admitted for haemetemesis. Investigations revealed markedly prolonged clotting times that recurred every few days despite administration of fresh frozen plasma and vitamin K. The derangement in coagulation lasted more than 3 months. In view of the absence of liver disease or malabsorption syndromes, long-acting anticoagulant ('superwarfarin') ingestion was suspected. The diagnosis of rodenticide poisoning was hampered by the lack of available assays. Diagnosis of brodifacoum intoxication using HPLC was confirmed only months after prolonged treatment with high dose vitamin K1. Superwarfarin poisoning should be suspected in cases of deranged coagulation refractory to treatment since these over-the-counter rodenticides are easily available.

Topics: 4-Hydroxycoumarins; Aged; Blood Coagulation Disorders; Humans; Male; Rodenticides

The vitamin K metabolism of three patients with factitious purpura due to brodifacoum ingestion was studied. These patients, who presented with bleeding disorders due to deficiency of the vitamin K-dependent blood clotting proteins, were refractory to vitamin K1 at standard doses and required fresh frozen plasma to control bleeding until large doses of vitamin K1 were used. Metabolic studies demonstrated a blockade in vitamin K utilization, consistent with the presence of a vitamin K antagonist, but the patients denied use of anticoagulants. Warfarin assays were negative. We show that the factitious purpura in each patient was due to the surreptitious ingestion of brodifacoum, a potent second generation long-acting vitamin K antagonist used as a rodenticide. The coagulopathies responded to long-term therapy with large doses of vitamin K1. The serum elimination half-time for brodifacoum ranged from 16 to 36 days in these patients. The anticoagulant effect is of long duration, requiring chronic vitamin K treatment. With increasing availability of new rodenticides, factitious purpura due to surreptitious ingestion of these potent vitamin K antagonists is emerging as a new problem, previously associated with warfarin, with important implications for diagnosis and treatment.

Topics: 4-Hydroxycoumarins; Administration, Oral; Adult; Blood Coagulation; Blood Coagulation Disorders; Dose-Response Relationship, Drug; Female; Humans; Male; Middle Aged; Purpura; Rodenticides; Vitamin K; Warfarin

This prospective study was undertaken to determine the incidence, severity, time of onset, and duration of coagulopathy in children following accidental ingestion of long-acting anticoagulant rodenticides, often called "superwarfarins." Of 110 children, who ingested superwarfarins and in whom one or more prothrombin time values were obtained, 8 had a prothrombin time ratio (patient to control) of greater than or equal to 1.2, indicative of anticoagulation. Prothrombin time values obtained 48 hours after ingestion were more likely to be prolonged (6/34, 17.6%) than values obtained 24 hours after ingestion (2/104, 1.9%) (P less than .005). The occurrence of an abnormal prothrombin time could not be predicted based on the history of amount ingested or on the presence of the characteristic green-blue product dye in or around the child's mouth. Acute toxicity was evidenced by transient abdominal pain, vomiting, and heme positive stools in 2 patients. The duration of prothrombin time prolongation could not be determined because of the few values obtained after 48 hours. To detect all possible abnormal prothrombin time values, 24- and 48-hour determinations are recommended after a child has ingested a superwarfarin.

Topics: 4-Hydroxycoumarins; Anticoagulants; Blood Coagulation Disorders; Child, Preschool; Humans; Infant; Prospective Studies; Prothrombin Time; Rodenticides; Time Factors

The case histories of two patients exposed to the novel anticoagulants brodifacoum and difenacoum are reported. Abnormal vitamin K1 metabolism, as indicated by elevated vitamin K1 2,3-epoxide plasma concentrations after i.v. administration of vitamin K1, could be detected for more than 18 months after exposure to the anticoagulants. There was a marked prolongation of prothrombin time (greater than 50 s) in both cases, at the time of exposure. However, subsequent haematological investigations (prothrombin time and vitamin K-dependent clotting factor activity) have been shown to be normal in both cases for at least 18 months. These cases confirm the long-acting nature of brodifacoum and difenacoum and present an apparent dissociation between the effect of coumarin anticoagulants on vitamin K1 metabolism and clotting factor activity.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Blood Coagulation Tests; Humans; Male; Occupational Diseases; Prothrombin Time; Vitamin K 1