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BMJCaseRep:-2021-
Rectussheathhaematomaduetodrug–drug
interaction
NikitaTheophilus,GhassanBachuwa
InternalMedicine,HurleyDESCRIPTION
MedicalCenter,Flint,Michigan,A-68-yearoldmanpresentedwithcomplaintsof
,hehadinfluenza-
likesymptomswithfeverashighas40°C,chills
-
DrGhassanBachuwa;
gbachuw2@mycin250mgdailyfor5
startedonazithromycin,heexperiencedabdom-
initiallyrestrictedtowardstherightmid-abdomen,
non-
paingraduallyincreasedinintensityoverthenext
2
toworseningabdominalpain,hesortedmedical
,
coronaryarterydiseaseandatrialfibrillationon
aspirin81 mgandapixaban5 mgtwotimesaday.
Onexamination, Apixabanactsasasubstrateforpermeability
Overlyingskinchangeswereabsent,butmultipleglycoprotein(P-gp)andcytochrome450enzymes.
(CYP3A4)isthepredominant
Ultrasoundoftheabdomenshowedarectussheathcytochrome(CYP)enzymethatmetabolisesapixaban.
× mminInducersandinhibitorsofP-gpandcytochromeP450
size(figure 1).Apixabandosewasloweredtohalfenzymescaninturndecreaseorincreasethelevelof
for1 week,,activatedfactorX;II,factor
weeks,thepainandswellingII;IIa,—Apixabaninhibitsfreeand
-—CytochromeP450enzyme
Apixabanwhichisanoveloralanticoagulantinhibitorsdecreasetherateofmetabolismandcan/
isadirectfactorXainhibitor(figure 2).(Thispicturehas
ofseveralindications,theonepertinenttothisbeencreatedandeditedbyNikitaTheophilus,MD,and
caseisstrokepreventioninnon-valvularatrialBrandonFlues,PharmD.)
bycytochromep450(CYP)
thedevelopmentofarectussheathhaematoma
to50%oftheprescribeddoseofapixabanis
(RSH)
recommendedinpatientsreceivingastrong
RSHshouldbesuspectedinpatientsonanti-
cytochromep450(CYP)
coagulantswhopresentwithabdominalpain
azithromycinisconsideredamildinhibitor
andabdominalswellingsinthesettingofsevereonAugust11,.
andthepresentliteraturedoesnotrecommend
-
adoseadjustment,itposesasariskfactorfor
onthepatient’
respondtosupportivemedicalcare,whichincludes
volumeresuscitationandsymptomaticmanage-
Learningpoints
►►Rectalsheathhaematoma(RSH)shouldbe
©BMJPublishingGroupsuspectedinpatientsonanticoagulants
re-use.Seerightsandpersistentcough.
.
►►AdiagnosisofRSHcanbemadebyultrasound
Tocite:Theophilus N,orCT.
Figureransverse1 planeTultrasoundoftheleftlower
Bachuwa ►►ConcomitantadministrationoffactorXa
abdominalwallshowingacysticmasswithinternal
Rep2021;14:(CYP)3A4
doi:-2021-septation,×,
inhibitorsincreasestheriskofbleeding.
242751suggestiveofrectussheathhaematoma.
Theophilus N,Bachuwa ;14::-2021-2427511
Imagesin…
BMJCaseRep:-2021-
Nonedeclared.
berestartedafterstabilisationofhaemoglobinandevidenceofPatientconsentforpublication Obtained.
Provenanceandpeerreview Notcommissioned;externallypeerreviewed.
after4 dayswasfoundtobesafeinmostofthepatients,with
thromboticcomplicationsoutnumberingbleedingepisodesinORCIDiD
patientswhereanticoagulationwaswithheldfortoolongafterGhassan Bachuwahttp://orcid.org/0000-0001-8414-0067
-
tionsshouldalwaysbeassessedwhenprescribingmedications
topatientsonanticoagulantsasbleedingepisodesmayprovetoREFERENCES
(apixaban)[prescribinginformation].NewYork,NY:PfzerInc2016.
2HillK,SuchaE,RhodesE,et
Contributors ;180:1052–60.
3SungaKL,BellolioMF,GilmoreRM,et
andthefnaldecisionmadetopublishthiscasereportwasacombineddecision.
hematoma:etiology,characteristics,management,
Funding Theauthorshavenotdeclaredaspecifcgrantforthisresearchfromany2012;43:e157–61.
fundingagencyinthepublic,commercialornot-for-,KehlJ,:whento
Disclaimer Casereportsprovideavaluablelearningresourceforthescientifcrestartanticoagulation?WorldJSurg2013;37:2555–9.
,GaronzikS,BoydRA,et :aclinicalpharmacokineticand
;58:1265–79.
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onAugust11,.
2Theophilus N,Bachuwa ;14::-2021-242751
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