CASE REPORT * ETUDE DE CAS
A
case of bromadiolone (superwarfarin) ingestion
Eudora Y. Chow,* MB, BS; Lawrence P. Haley,* MD, FRCPC; Linda M. Vickars,t MD, FRCPC; Michael J. Murphy,: DVM, PhD
The patient was anxious and had numerous W ith the emergence of warfarin-resistant rats the new hydroxycoumarin compounds bruises over the arms and legs and the abdomen. that have been developed as potent roden- Petechiae were present in the distribution of the ticides have gained increasing popularity.' These scratch marks. Laboratory tests revealed a hemoglobin level of anticoagulant compounds include brodifacoum, difenacoum, bromadiolone, diphacinone and chlor- 114 g/L, a leukocyte count of 5.1 x 109/L and a phacinone and are termed "superwarfarins" or platelet count of 620 x 109/L. The prothrombin time (PT) was 35.6 (normally 11 to 13) seconds and the "long-acting anticoagulants."2 Patients who have ingested superwarfarin usual- partial thromboplastin time (PTT) 57.3 (normally 24 ly present with unexplained bleeding, the cause of to 36) seconds. The thrombin time and plasma which can be difficult to diagnose. We feel that fibrinogen level were normal. The addition of norphysicians should know the consequences of ingest- mal plasma in a 1:1 ratio resulted in complete ing these compounds, since they are now widely correction of the coagulation abnormalities with a available. There have been scattered reports of their return to normal of the PT and PTT; a coagulation ingestion,3-' and most of these have implicated factor deficiency was suspected. Urinalysis revealed brodifacoum. We report a case involving bromadio- microscopic hematuria. The results of factor assays were consistent with lone, one of the most common agents in accidental ingestion in British Columbia. To our knowledge vitamin K deficiency: the level of factor II was 0.10 this is the second reported case in the world litera- U/mL, of factor VII 0.03 U/mL and of factor X 0.10 U/mL (all normally 0.70 to 1.30 U/mL); the levels of ture. factors V and VIII were within normal limits. Warfarin abuse was suspected because no other Case report cause of vitamin K deficiency could be elicited. A 27-year-old female nurse was noted to have However, analysis of two blood samples for warfarin extensive bruising at the time of a routine pre- gave negative results. The patient was treated subcutaneously with 10 employment medical examination. She also complained of menorrhagia, mild epistaxis and extensive mg of vitamin K,; 22 hours later her PT and PTT petechiae associated with scratching. She recalled remained extended, at 27.6 and 61.1 seconds respecseveral uneventful surgical procedures in the past, tively. After 3 days the PT and PTT were 32.3 and including a laparotomy for suspected Crohn's dis- 60.6 seconds, and a larger dose of vitamin KI, 20 ease. There was no history of liver disease or mental mg, was administered subcutaneously. The patient's illness, and she denied taking anticoagulants or PT and PTT returned to normal 3 weeks later without further intervention. acetylsalicylic acid. From the divisions of *Laboratory Hematology and tClinical Hematology, St. Paul's Hospital, Vancouver, Veterinary Diagnostic Medicine, College of Veterinary Medicine, University of Minnesota, St. Paul, Minn. Dr. Murphy is a member of the American Board of Veterinary
BC, and tthe Department of
Toxicology.
Reprint requests to: Dr. Eudora Y. Chow, Division of Laboratory Hematology, St. Paul's Hospital, 1081 Burrard St., Vancouver, BC V6Z I Y6 60
CAN MED ASSOC J 1992; 147 (1)
LE ler JUILLET 1992
The patient's failure to respond to vitamin K treatment and the absence of warfarin in her blood led us to suspect the ingestion of superwarfarin. A serum sample was sent to the reference laboratory at the Department of Veterinary Diagnostic Medicine, College of Veterinary Medicine, St. Paul, Minn., for investigation by a reported method.8 The results showed the presence of bromadiolone at a concentration of 40 ng/mL. The patient repeatedly denied any contact with a rodenticide. A psychiatric consultation was arranged. She was seen again 1 year later and did not show any evidence of bleeding or bruising. Her PT was 12.2 and her PTT 34.4 seconds. Factor assay results were normal, and there was no evidence of bromadiolone in the serum.
Comments With the increasing availability of second-generation vitamin K antagonists marketed as rodenticides, physicians need to be aware of the possibility of surreptitious use of or accidental poisoning with these superwarfarins. In British Columbia 99 cases of anticoagulant rodenticide ingestion were documented by the British Columbia Drug and Poison Information Centre, Vancouver, from Jan. 1, 1989, to June 15, 1991; 42 cases involved bromadiolone. 0 °
0)
CH3
A
case of bromadiolone (superwarfarin) ingestion
Eudora Y. Chow,* MB, BS; Lawrence P. Haley,* MD, FRCPC; Linda M. Vickars,t MD, FRCPC; Michael J. Murphy,: DVM, PhD
The patient was anxious and had numerous W ith the emergence of warfarin-resistant rats the new hydroxycoumarin compounds bruises over the arms and legs and the abdomen. that have been developed as potent roden- Petechiae were present in the distribution of the ticides have gained increasing popularity.' These scratch marks. Laboratory tests revealed a hemoglobin level of anticoagulant compounds include brodifacoum, difenacoum, bromadiolone, diphacinone and chlor- 114 g/L, a leukocyte count of 5.1 x 109/L and a phacinone and are termed "superwarfarins" or platelet count of 620 x 109/L. The prothrombin time (PT) was 35.6 (normally 11 to 13) seconds and the "long-acting anticoagulants."2 Patients who have ingested superwarfarin usual- partial thromboplastin time (PTT) 57.3 (normally 24 ly present with unexplained bleeding, the cause of to 36) seconds. The thrombin time and plasma which can be difficult to diagnose. We feel that fibrinogen level were normal. The addition of norphysicians should know the consequences of ingest- mal plasma in a 1:1 ratio resulted in complete ing these compounds, since they are now widely correction of the coagulation abnormalities with a available. There have been scattered reports of their return to normal of the PT and PTT; a coagulation ingestion,3-' and most of these have implicated factor deficiency was suspected. Urinalysis revealed brodifacoum. We report a case involving bromadio- microscopic hematuria. The results of factor assays were consistent with lone, one of the most common agents in accidental ingestion in British Columbia. To our knowledge vitamin K deficiency: the level of factor II was 0.10 this is the second reported case in the world litera- U/mL, of factor VII 0.03 U/mL and of factor X 0.10 U/mL (all normally 0.70 to 1.30 U/mL); the levels of ture. factors V and VIII were within normal limits. Warfarin abuse was suspected because no other Case report cause of vitamin K deficiency could be elicited. A 27-year-old female nurse was noted to have However, analysis of two blood samples for warfarin extensive bruising at the time of a routine pre- gave negative results. The patient was treated subcutaneously with 10 employment medical examination. She also complained of menorrhagia, mild epistaxis and extensive mg of vitamin K,; 22 hours later her PT and PTT petechiae associated with scratching. She recalled remained extended, at 27.6 and 61.1 seconds respecseveral uneventful surgical procedures in the past, tively. After 3 days the PT and PTT were 32.3 and including a laparotomy for suspected Crohn's dis- 60.6 seconds, and a larger dose of vitamin KI, 20 ease. There was no history of liver disease or mental mg, was administered subcutaneously. The patient's illness, and she denied taking anticoagulants or PT and PTT returned to normal 3 weeks later without further intervention. acetylsalicylic acid. From the divisions of *Laboratory Hematology and tClinical Hematology, St. Paul's Hospital, Vancouver, Veterinary Diagnostic Medicine, College of Veterinary Medicine, University of Minnesota, St. Paul, Minn. Dr. Murphy is a member of the American Board of Veterinary
BC, and tthe Department of
Toxicology.
Reprint requests to: Dr. Eudora Y. Chow, Division of Laboratory Hematology, St. Paul's Hospital, 1081 Burrard St., Vancouver, BC V6Z I Y6 60
CAN MED ASSOC J 1992; 147 (1)
LE ler JUILLET 1992
The patient's failure to respond to vitamin K treatment and the absence of warfarin in her blood led us to suspect the ingestion of superwarfarin. A serum sample was sent to the reference laboratory at the Department of Veterinary Diagnostic Medicine, College of Veterinary Medicine, St. Paul, Minn., for investigation by a reported method.8 The results showed the presence of bromadiolone at a concentration of 40 ng/mL. The patient repeatedly denied any contact with a rodenticide. A psychiatric consultation was arranged. She was seen again 1 year later and did not show any evidence of bleeding or bruising. Her PT was 12.2 and her PTT 34.4 seconds. Factor assay results were normal, and there was no evidence of bromadiolone in the serum.
Comments With the increasing availability of second-generation vitamin K antagonists marketed as rodenticides, physicians need to be aware of the possibility of surreptitious use of or accidental poisoning with these superwarfarins. In British Columbia 99 cases of anticoagulant rodenticide ingestion were documented by the British Columbia Drug and Poison Information Centre, Vancouver, from Jan. 1, 1989, to June 15, 1991; 42 cases involved bromadiolone. 0 °
0)
CH3
