Case report
A 31-year-old man weighing 70 kg with a history of fatty liver was sent
to our emergency department due to chest pain and dyspnea for 7 days and
fever for 4 days. His highest temperature was 40°C and he occasionally
coughed without expectoration or hemoptysis. His d-dimer was 0.77 mg/L,
alanine aminotransferase (ALT) was 98 U/L, aspartate aminotransferase
(AST) was 60 U/L, total bilirubin (TBIL) was 8.7 mol/L, and Albumin was
43.8 g/L. His prothrombin time (PT) was 13.4 s, fibrinogen concentration
was 5.00 g/L, and serum creatinine (CR) was 68 mol/L. The computer
tomography pulmonary angiography (CTPA) showed the following results: 1.
There was a high possibility of embolization of multiple small branches
of the left pulmonary artery. The heart shadow increased and the
ventricular wall slightly thickened. 2. Both lungs were scattered with
inflammation, centered at the left lower lobe. 3. A small amount of
pleural effusion was observed on the left side, with inadequate
expansion of adjacent lung tissues. Abdominal ultrasound showed 1) fatty
and large liver, 2) less smooth gallbladder wall, and 3) no obvious
abnormalities in spleen and pancreas. He was subsequently admitted to
our hospital and started
anticoagulant therapy with 0.6 mL low molecular weight sodium heparin
injection, given subcutaneously
every 12 h.
Epistaxis
and hematuria (Red 78.8/μL) were present on the second day of admission.
We determined it was a side effect of LMWH. Then we reduced the dose of
low molecular weight sodium heparin injection to 0.4 ml, given
subcutaneously every 12 h. After reducing the dose, the patient did not
have obvious symptoms such as epistaxis and hematuria any more. His
D-dimer was 11.16 mg/L, ALT was 317 U/L, AST was 177 U/L, DBIL was 23.7
μmol/L, TBIL was 33.4 μmol/L, PT was 12.0 s, PT-INR was 1.05, and Fbg C
was 6.65 g/L. His high ALT and AST level may be due to the
out-of-hospital use of antipyretics. Both levels recovered after the
administration of glutathione (2 g, once daily) and polyene
phosphatidylcholine injection (10 ml, once daily) for three days. For
his pneumonia, cefoperazone (2 g, twice daily) was administrated for 7
days. On Day 10, due to the inconvenience of subcutaneous injection,
LMWH was discontinued and replaced with Rivaroxaban 15 mg administered
orally twice daily. His ALT level was 73 U/L, AST was 25 U/L, D-dimer
was 8.00 mg/L, WBC was 7.23×109/L, and NEU% was
65.0%. He was discharged from our hospital, continuing oral
anticoagulants after discharge. After
three weeks of rivaroxaban treatment, the patient’s blood routine tests
were normal, without any side effect.