Massive thrombosis and phlegmasia cerulea dolens while taking rivaroxaban: case report and review

Abstract

Our study describes a fatal case of phlegmasia cerulea dolens and massive venous thrombosis in a patient taking rivaroxaban regularly to treat cerebral venous sinus thrombosis. Blood tests samples were positive for lupus anticoagulant. The unique evolution of the case, as well as the positivity for lupus anticoagulant, raises the possibility of an acquired hypercoagulation syndrome. We highlight the fact that the test recommended as the first line for lupus anticoagulant diagnosis (dilute Russell viper venom time) is the most affected by rivaroxaban, leading to a high prevalence of false-positive results. We also discuss potential diagnoses for the current case and review the current state-of-the-art of use of the novel oral anticoagulation agents in this unusual situation. So far, there are no recommendations to use such agents as first options in cerebral venous sinus thrombosis or in hypercoagulation syndromes.

Keywords: anticoagulants; sinus thrombosis, intracranial; venous thrombosis.

Figure 1. Images from Case: Massive left leg edema with cyanosis (A). Venous ultrasound with Doppler of the common left iliac vein showing no venous flow and absence of compression; signs compatible with deep vein thrombosis (B). Non-contrast enhanced computed tomography scan showing signs of cerebral venous thrombosis. The images show dense clot signs in the sagittal and right transverse sinuses (red arrows) (C, D) and left temporoparietal hemorrhage with surrounding edema (yellow arrowheads) (C).