ABC | Volume 114, Nº4, Suplement, April 2020

Case Report A Life-threatening Combination: Indomethacin and Dabigatran Adem Adar, 1 Orhan Onalan, 1 Fahri Cakan 1 Karabuk University Faculty of Medicine – Cardiology, 1 Karabuk – Turkey Introduction Although rare, several bleeding complications may occur in patients receiving dabigatran. The risk of bleeding is particularly high in patients with impaired kidney functions or in patients who are on concomitant nephrotoxic drugs. 1 We report a case of massive pleuropericardial effusion developed after the initiation of indomethacin treatment in a patient who was receiving dabigatran for deep venous thrombosis. Case Report A 50-year old male patient admitted to the emergency department with progressive dyspnea. He had a heart rate of 120 beats/min, blood pressure of 180/90 mmHg, respiration rate of 15 breaths/min, oxygen saturation of 95% (on room air) and temperature of 36.8 º С at presentation. He had a sedentary lifestyle, obesity (body mass index: 31 kg/m 2 ), uncontrolled hypertension (for 5 years without medical therapy) and deep vein thrombosis (on dabigatran 150 mg twice a day for 50 days). Twenty days prior to his presentation, he started to receive indomethacin (once a day) for his leg pain. On physical examination, he had diminished heart and lung sounds. Electrocardiography showed sinus tachycardia. Cardiomegaly and bilateral pleural effusion (greater on the left lung) were noticed on chest X-ray. Chest computerized tomography confirmed bilateral pleural effusion and revealed massive pericardial effusion (Figure 1A). On admission, his blood tests were as follows: glucose: 107 mg/dL, urea: 63 mg/dL, creatinine: 1.99 mg/dL, AST: 69 U/L, ALT: 99 U/L, white blood cells: 9.73 10 9 /L, hemoglobin: 9.6 mg/dL, C-reactive protein: 0.9 mg/dL, activated partial thromboplastin time (APTT): 91.4-seconds and international normalized ratio (INR): 2.5. Since his last creatinine level was 1.1 mg/dL 20 days before (just before the initiation of indomethacin treatment), acute renal failure was considered. The patient was admitted to the intensive care unit and detailed echocardiography was performed. Transthoracic echocardiography revealed normal left ventricular systolic function (EF 65%), left ventricular concentric hypertrophy (LVMI: 118 g/m 2 ), massive pericardial and pleural effusion (Figure 1B). There were no signs of cardiac tamponade on the first echocardiographic evaluation. However, during follow-up, his dyspnea and tachycardia were gradually increased, and right ventricular diastolic collapse was noticed on control echocardiography. We decided to perform urgent pericardiocentesis. In order to reduce the risk of bleeding, idarucizumab was administered (total 5 grams divided into two consecutive infusions of 2.5 grams) before pericardiocentesis. Two hours after administration of idarucizumab, the APTT value decreased to 44 seconds. Pericardiocentesis was performed with echocardiography guidance. Approximately 3L of blood-red, non-coagulating pericardial fluid was drained out (Figure 2). Pericardial fluid analysis was negative for gram staining, cytology, polymerase Mailing Address: Adem Adar • Karabuk University Faculty of Medicine – Cardiology - Karabuk 78050 – Turkey E-mail: dradaradem@gmail.com manuscript received August 20, 2018, revised manuscript December 19, 2018, accepted February 13, 2019 Keywords Indomenthacin/administration & dosage; Dabigatran/ administration & dosage; Cardiomegaly; Pleural Effusion; Renal Insufficiency; Echocardiography. DOI: https://doi.org/10.36660/abc.20180159 Figure 1 – A) Massive pericardial and pleural effusion in thoracic tomography. B) Pericardial effusion surrounding the heart and pleural effusion. C) Pericardial effusion was drained completely. 13