A rare case of fondaparinux-induced major bleeding in postmenopausal woman prescribed for non-ST segment elevation Ml
We hereby report a rare case of fondaparinux-induced major bleeding in a 58-year-old postmenopausal woman, a known hypertensive and Type 2 diabetes mellitus (T2DM) patient prescribed for NSTEMI reported in our ADRM Centre.\nThe patient presented in the emergency with complaints of chest pain not relieved by sublingual nitrate. On examination there was no pallor, cyanosis, pedal edema, signs of atherosclerosis. Pulse rate was 94/min, regular, normal volume, no radio-femoral delay, and vessel wall not palpable. Blood pressure (BP) measured in both limbs was 160/90 mmHg. On auscultation of CVS and respiratory system showed no abnormality. Laboratory investigations revealed Hb 11g%, TLC 8400/cmm, platelet count 2.4 lacs/cmm, RBS 194 mg%, blood urea 29 mg, serum creatinine 0.9 mg, HbA1c 7.8%, serum cholesterol 245 mg%, serum triglyceride 185 mg%, HDL 35 mg%.\nECG was done immediately, which showed NSTEMI and a positive 10 hour troponin-T assay. Angiography was not done. Patient was treated with oxygen, morphine, beta blocker, ACE inhibitor, statins, aspirin, and clopidogrel, fondaparinux 2.5 mg once daily by subcutaneous route. Third day patient developed purpura and extensive ecchymosis in right arm and forearm [Figures and ]. The patient also developed epistaxis lasting >10 min, which required ENT intervention as well as macroscopic hematuria lasting for 3 days. Patient also presented with per vaginal bleeding, which continued till 7 days. Patient on subsequent investigations showed platelet count 45000/cmm. Hb was 6.9 g%. HIT antibodies were not done due to lack of facility. There were no signs of deep venous thrombosis, pulmonary embolism, gangrene, retroperitoneal, intracranial, or intraocular hemorrhage in the patients as suggested by USG abdomen and MRI brain. USG of pelvic organ revealed small postmenopausal sized uterus and normal adnexa. Based on clinical and laboratory findings, a diagnosis of fondaparinux-induced major bleeding was established. Patient required four units of platelet fraction and three unit of blood transfusion. After which platelet count and Hb rapidly reestablished to 1.5 L/cmm and 8.9 g%. She was discharged in a satisfactory condition after 15 days of hospitalization and is now regular follow up and prophylaxis treatment of MI. Since the ADR was serious and most likely thought to be associated with fondaparinux because of its previous known few reports.[]\nDe-challenge of drug and blood/platelet transfusion caused ADR to ameliorate. Further re-challenge was not done with the fear of reappearance of ADR and due to ethical constrains. Thus, the appearance of major bleeding could not be explained by a concurrent disease as such, drug or chemicals and de-challenge improved the condition.