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.