P0813 - Hyperfibrinolysis in the Setting of Retroperitoneal Hematoma Secondary to Psoas Tear in Patient With Decompensated Liver Cirrhosis and Possible Hepatotoxicity From Ciprofloxacin

Loren R. Schubert, DO, Claudine Curioso-Hughes, DO, Joshua Jaeger, DO, Emily Dryer, DO, Thomas Birris, MD, Daniel Douce, MD, Michael Wang, MD, Naveen Vijayam, DO
Spectrum Health Lakeland, St. Joseph, MI

Introduction: Tendinopathies are a well-known complication of fluoroquinolones, certain quinolones such as Ciprofloxacin are also linked to liver injury. Hyperfibrinolysis, or the rare hyperactivation of the fibrinolytic pathway is found in 5-10% of patients with end-stage liver disease. Here we present a 47-year-old male who presented with a rare case of hyperfibrinolysis after exposure to Ciprofloxacin.

Case Description/Methods: A 47-year-old male with history of alcoholic cirrhosis presented to the emergency department with right groin pain. He was being treated with Ciprofloxacin for K. oxytoca and P. rettgeri bacteremia. Physical exam demonstrated tenderness of the right groin with passive and active range-of-motion, right groin hematoma, and diffuse petechiae. Subsequent work-up was remarkable for CT abdomen/pelvis demonstrating moderate ascites and retroperitoneal hematoma centering near the distal right psoas. INR >27.0.

Hematology was consulted after Vitamin K failed to improve coagulopathy in setting of worsening anemia. He was treated with Vitamin K, cryoprecipitate and FFP. Additional studies were completed and demonstrated undetectable fibrinogen, elevated D-dimer and INR; consistent with hyperfibrinolysis. The patient was subsequently treated with ε-aminocaproic acid with transient improvement in coagulopathy, then worsening coagulopathy. He was discharged on hospice and expired 72 hours later.

Discussion: Hyperfibrinolysis, is caused by dysregulation of the fibrinolytic pathway. Acquired hyperfibrinolysis is associated with malignancies, cirrhosis, liver transplants, cardiopulmonary bypass, and envenomation syndromes from certain snakes. Hyperfibrinolysis can be difficult to diagnose due to lack of widely accepted criteria and limitations of current testing. Viscoelastic testing such as thromboelastography allows a dynamic picture of the entire coagulation process, however, its use is limited due to availability. More widely available testing may be useful in the initial evaluation when differentiating DIC from hyperfibrinolysis, which present similarly. Factor VIII is decreased in DIC and normal in hyperfibrinolysis. Stable platelet counts and absence of schistocytes on peripheral smear are indicative of hyperfibrinolysis.

Ciprofloxacin has been linked to hepatotoxicity and risk of adverse events are more frequent in comorbid conditions. We hypothesize that Ciprofloxacin, used in the setting of cirrhosis, contributed to dysregulation of the fibrinolytic pathway leading to hyperfibrinolysis.




Disclosures:


Loren R. Schubert, DO, Claudine Curioso-Hughes, DO, Joshua Jaeger, DO, Emily Dryer, DO, Thomas Birris, MD, Daniel Douce, MD, Michael Wang, MD, Naveen Vijayam, DO. P0813 - Hyperfibrinolysis in the Setting of Retroperitoneal Hematoma Secondary to Psoas Tear in Patient With Decompensated Liver Cirrhosis and Possible Hepatotoxicity From Ciprofloxacin, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.