Canadian Journal of Cardiology
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(2013) 1.e1e1.e2 www.onlinecjc.ca
Case Report
Spontaneous Chest Wall Hematoma With Dual Antiplatelet Therapy Priscilla Bevan, MBChB, Ashvini Menon, MBBS, MRCS, and Richard Bunton, MBChB, FRACS, FRCSEd(C/Th) Department of Cardiothoracic Surgery, Dunedin Hospital, Dunedin, New Zealand
ABSTRACT
RESUM E
Spontaneous chest wall hematoma is rare and has been associated with neoplasms and arteriovenous malformations. However, the increasing use of anticoagulant and antiplatelet agents has increased the clinical presentation of spontaneous hematomas. Clopidrogel and aspirin are antiplatelet agents widely used in the treatment of peripheral vascular, cerebrovascular, and coronary artery disease. Although bleeding is a known adverse effect, only a small number of cases of hematomas associated with antiplatelet agents have been described. We report a case of a large spontaneous latissimus dorsi hematoma in a patient receiving clopidogrel and aspirin therapy.
matome spontane de la paroi thoracique est rare, et a e te associe L’he oplasmes et aux malformations arte rioveineuses. Cependant, aux ne l’utilisation croissante des anticoagulants et des antiplaquettaires ont dans le tableau clinique une augmentation des he matomes entraîne s. Le clopidogrel et l’aspirine sont des antiplaquettaires spontane s dans le traitement de la maladie vasculaire largement utilise riphe rique, de la maladie ce re brovasculaire et de la coronaropathie. pe morragie soit un effet inde sirable connu, seul un petit Bien que l’he matomes a e te associe aux antiplaquettaires. Nous rapnombre d’he matome spontane important au grand dorsal chez portons un cas d’he un patient recevant le traitement par clopidogrel et aspirine.
Case Report A 79-year-old man presented to the Emergency Department with an 8-day history of gradually worsening left-sided back pain and swelling. There were no precipitating factors, trauma, or strenuous exertion. The pain was constant and exacerbated by movement of the left upper limb. He was receiving aspirin and clopidogrel therapy after coronary artery stenting 4 months earlier. In addition, he was receiving medical management for hyperlipidemia and hypertension. Clinical examination revealed a well built hemodynamically stable patient. There was a tender swelling in the left posterior chest wall with significant bruising extending to the left lower back and flank (Fig 1A and B). On admission, hemoglobin was 133 g/dL, and platelet and coagulation profile were normal. Chest x-ray was unremarkable. Ultrasound scan revealed a 9.6 6.8 2.3 cm hypoechoic mass consistent with a hematoma between the latissimus dorsi and the posterior ribs. A computed tomography scan showed a 150 40 mm heterogeneous area, consistent with hematoma, deep to the latissimus dorsi on the
left (Fig 1C) with tracking of fluid from the level of the hematoma down to the pelvis and the anterolateral abdominal wall. No other pathology to account for the bleeding was identified on the computed tomography scan. Further coagulation testing and review by the hematologist did not reveal any coagulation abnormalities other than that attributed to antiplatelet therapy. He was managed conservatively with analgesia. Over the subsequent 5 days, his hemoglobin dropped to 76 g/dL, and he received a blood transfusion. After discussion with his cardiologist, the clopidogrel was discontinued. He was discharged home 8 days after admission, with a hemoglobin level of 104 g/dL. At 6-week follow-up, the chest wall hematoma and bruising had resolved with no limitation in upper limb movement.
Received for publication August 10, 2013. Accepted August 30, 2013. Corresponding author: Dr Ashvini Menon, Department of Cardiothoracic Surgery, Dunedin Hospital, Great King Street, Dunedin 9016, New Zealand. Tel.: þ447973674826. E-mail: [email protected] See page 1.e2 for disclosure information.
Discussion Clopidogrel is an oral antiplatelet agent used in the treatment of coronary artery, peripheral vascular, and cerebrovascular disease. It prolongs bleeding time and delays clot retraction. The bleeding complications of dual antiplatelet therapy are well recognized. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial, investigating the use of clopidogrel in addition to aspirin in patients with acute coronary syndromes, reported significant and
0828-282X/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc on behalf of the Canadian Cardiovascular Society. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.08.021
1.e2
Canadian Journal of Cardiology Volume - 2013
Figure 1. (A, B) Posterior chest wall hematoma tracking down to the left flank. (C) Chest wall hematoma deep to the lattisimus dorsi on the left.
life-threatening bleeding in 3.7% and 2.1% respectively.1 This is comparable with major bleeding reported with dabigatran therapy.2 Clopidogrel therapy has also been associated with spontaneous retroperitoneal, ovarian, and abdominal and epidural hematoma formation.3-5 Our case report describes a posterior spontaneous chest wall hematoma with clopidogrel and aspirin therapy. Clinicians should be mindful of the presentation of chest wall hematoma in patients given dual antiplatelet therapy. Disclosures The authors have no conflicts of interest to disclose. References 1. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary
syndromes without ST- segment elevation. N Engl J Med 2001;345: 494-502. 2. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-51. 3. Jurisic D, Doko M, Glavan E, Vidovic D, Matkovic K, Pitlovic V. Spontaneous retroperitoneal haematoma associated with clopidogrel therapy mimicking acute appendicitis. Br J Clin Pharmacol 2006;62: 248-9. 4. Ozlu T, Ozlu MF, Ayhan A. Spontaneous ovarian hematoma in a patient treated with clopidogrel. Int J Gynaecol Obstet 2008;102:293-4. 5. Otrock ZK, Sawaya JI, Zebian RC, Taher AT. Spontaneous abdominal hematoma in a patient treated with clopidogrel and aspirin. Ann Hematol 2006;85:743-4.
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(2013) 1.e1e1.e2 www.onlinecjc.ca
Case Report
Spontaneous Chest Wall Hematoma With Dual Antiplatelet Therapy Priscilla Bevan, MBChB, Ashvini Menon, MBBS, MRCS, and Richard Bunton, MBChB, FRACS, FRCSEd(C/Th) Department of Cardiothoracic Surgery, Dunedin Hospital, Dunedin, New Zealand
ABSTRACT
RESUM E
Spontaneous chest wall hematoma is rare and has been associated with neoplasms and arteriovenous malformations. However, the increasing use of anticoagulant and antiplatelet agents has increased the clinical presentation of spontaneous hematomas. Clopidrogel and aspirin are antiplatelet agents widely used in the treatment of peripheral vascular, cerebrovascular, and coronary artery disease. Although bleeding is a known adverse effect, only a small number of cases of hematomas associated with antiplatelet agents have been described. We report a case of a large spontaneous latissimus dorsi hematoma in a patient receiving clopidogrel and aspirin therapy.
matome spontane de la paroi thoracique est rare, et a e te associe L’he oplasmes et aux malformations arte rioveineuses. Cependant, aux ne l’utilisation croissante des anticoagulants et des antiplaquettaires ont dans le tableau clinique une augmentation des he matomes entraîne s. Le clopidogrel et l’aspirine sont des antiplaquettaires spontane s dans le traitement de la maladie vasculaire largement utilise riphe rique, de la maladie ce re brovasculaire et de la coronaropathie. pe morragie soit un effet inde sirable connu, seul un petit Bien que l’he matomes a e te associe aux antiplaquettaires. Nous rapnombre d’he matome spontane important au grand dorsal chez portons un cas d’he un patient recevant le traitement par clopidogrel et aspirine.
Case Report A 79-year-old man presented to the Emergency Department with an 8-day history of gradually worsening left-sided back pain and swelling. There were no precipitating factors, trauma, or strenuous exertion. The pain was constant and exacerbated by movement of the left upper limb. He was receiving aspirin and clopidogrel therapy after coronary artery stenting 4 months earlier. In addition, he was receiving medical management for hyperlipidemia and hypertension. Clinical examination revealed a well built hemodynamically stable patient. There was a tender swelling in the left posterior chest wall with significant bruising extending to the left lower back and flank (Fig 1A and B). On admission, hemoglobin was 133 g/dL, and platelet and coagulation profile were normal. Chest x-ray was unremarkable. Ultrasound scan revealed a 9.6 6.8 2.3 cm hypoechoic mass consistent with a hematoma between the latissimus dorsi and the posterior ribs. A computed tomography scan showed a 150 40 mm heterogeneous area, consistent with hematoma, deep to the latissimus dorsi on the
left (Fig 1C) with tracking of fluid from the level of the hematoma down to the pelvis and the anterolateral abdominal wall. No other pathology to account for the bleeding was identified on the computed tomography scan. Further coagulation testing and review by the hematologist did not reveal any coagulation abnormalities other than that attributed to antiplatelet therapy. He was managed conservatively with analgesia. Over the subsequent 5 days, his hemoglobin dropped to 76 g/dL, and he received a blood transfusion. After discussion with his cardiologist, the clopidogrel was discontinued. He was discharged home 8 days after admission, with a hemoglobin level of 104 g/dL. At 6-week follow-up, the chest wall hematoma and bruising had resolved with no limitation in upper limb movement.
Received for publication August 10, 2013. Accepted August 30, 2013. Corresponding author: Dr Ashvini Menon, Department of Cardiothoracic Surgery, Dunedin Hospital, Great King Street, Dunedin 9016, New Zealand. Tel.: þ447973674826. E-mail: [email protected] See page 1.e2 for disclosure information.
Discussion Clopidogrel is an oral antiplatelet agent used in the treatment of coronary artery, peripheral vascular, and cerebrovascular disease. It prolongs bleeding time and delays clot retraction. The bleeding complications of dual antiplatelet therapy are well recognized. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial, investigating the use of clopidogrel in addition to aspirin in patients with acute coronary syndromes, reported significant and
0828-282X/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc on behalf of the Canadian Cardiovascular Society. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.08.021
1.e2
Canadian Journal of Cardiology Volume - 2013
Figure 1. (A, B) Posterior chest wall hematoma tracking down to the left flank. (C) Chest wall hematoma deep to the lattisimus dorsi on the left.
life-threatening bleeding in 3.7% and 2.1% respectively.1 This is comparable with major bleeding reported with dabigatran therapy.2 Clopidogrel therapy has also been associated with spontaneous retroperitoneal, ovarian, and abdominal and epidural hematoma formation.3-5 Our case report describes a posterior spontaneous chest wall hematoma with clopidogrel and aspirin therapy. Clinicians should be mindful of the presentation of chest wall hematoma in patients given dual antiplatelet therapy. Disclosures The authors have no conflicts of interest to disclose. References 1. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary
syndromes without ST- segment elevation. N Engl J Med 2001;345: 494-502. 2. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-51. 3. Jurisic D, Doko M, Glavan E, Vidovic D, Matkovic K, Pitlovic V. Spontaneous retroperitoneal haematoma associated with clopidogrel therapy mimicking acute appendicitis. Br J Clin Pharmacol 2006;62: 248-9. 4. Ozlu T, Ozlu MF, Ayhan A. Spontaneous ovarian hematoma in a patient treated with clopidogrel. Int J Gynaecol Obstet 2008;102:293-4. 5. Otrock ZK, Sawaya JI, Zebian RC, Taher AT. Spontaneous abdominal hematoma in a patient treated with clopidogrel and aspirin. Ann Hematol 2006;85:743-4.
