Spontaneous Hemothorax as a Complication of Apixaban Treatment

Abstract Introduction: Hemothorax is a bloody pleural fluid collection greater than 50% of a patient's hematocrit. It usually occurs by coagulopathy, trauma, or invasive procedures. Spontaneous hemothorax occurs without any history of trauma or iatrogenic etiology. Associated causes include coagulopathy, pneumothorax, pulmonary vascular malformation, and aortic dissection. The clinical presentation varies and can rapidly progress to hemodynamic instability. We present a case of spontaneous hemothorax in a patient who was on apixaban for atrial fibrillation. Case description: 86-year-old man with a history of paroxysmal atrial fibrillation, coronary artery disease, heart failure with reduced ejection fraction, hypertension, chronic kidney disease presented with shortness of breath. Lab work showed leukocytosis, coagulation profile was significant for anemia and elevated INR. Arterial blood gas showed hypoxemia. X-ray chest showed a near collapse of the right lung with a large pleural effusion. He did not have any prior history of bleeding disorder or underlying malignancy, arteriovenous malformations, or connective tissue disorder. CT chest showed a large right-sided hemothorax. A chest tube was placed to water seal with a 2.7-liter bloody output. After chest tube placement, the X-ray chest showed near complete evacuation of the right pleural fluid collection. His oxygen requirements improved over time and the chest tube was removed. After a few days, his repeat X-ray chest was done to ensure resolution of hemothorax which showed moderate to large volume of right pleural fluid. CT imaging was done to rule out effusion versus reaccumulating hemothorax which showed a large amount of grossly unchanged hemothorax on the right and new loculated pleural effusion within high posterior and right hemithorax. He underwent video-assisted thoracic surgical (VATS) decortication with improvement of symptoms subsequently. Repeat imaging was normal. On discharge, anticoagulation was held off after shared decision-making. Discussion: Apixaban, a direct-acting oral anticoagulant, provides a superior risk-benefit profile for stroke prevention in individuals with clinical atrial fibrillation. Gastrointestinal and cerebral hemorrhage are commonly encountered side effects of anticoagulation, but spontaneous hemothorax is uncommon, especially without the presence of pre-existing vascular abnormalities, genetic disorders, or lung diseases. Management includes immediate fluid resuscitation, blood transfusion, and tube thoracostomy for hemothorax drainage. After chest tube placement, the surgical approach should be considered either in the form of VATS or open thoracotomy with shorter postoperative hospitalization and fewer postoperative complications with VATS. Physicians should consider spontaneous hemothorax as one of the contributing etiologies when diagnosing new pleural effusion in patients receiving anticoagulation therapy.