Thoracic aorta pseudoaneurysm with hemopericardium: unusual presentation of warfarin overdose

A patient with a pseudoaneurysm will typically have had a traumatic event such as a recent blunt or penetrating trauma, or an endovascular procedure[1,2]. Heart failure and chest pain are the most common manifestations of a pseudoaneurysm of the ascending aorta[3]. Herein we report the case of a female receiving warfarin whose international normalized ratio (INR) was >10, who presented with dyspnea. Chest computed tomography (CT) revealed an aortic arch pseudoaneurysm and a fluid collection suggesting blood in the pericardium. We discuss the risk of bleeding as it is related to warfarin overdose and pseudoaneurysm leakage.A 78-year-old female, presenting with progressive shortness of breath and general weakness was admitted to our hospital on March 15, 2010. She experienced palpitations and tachycardia, and mild chest tightness when palpitations occurred. Her history was significant for primary cancer of the appendix with ovarian metastases, and was status post a debunking operation in December of 2006, complicated by chronic right leg lymphedema. She had been taking warfarin as prescribed by the cardiovascular surgery department for deep vein thrombosis of the right leg.On admission, her blood pressure was 148/96 mmHg, heart rate 114 beats/min, respiratory rate 26 breaths/min, and temperature 37.8°C. Laboratory studies revealed: white blood cell (WBC) count, 17200/uL (neutrophil-segment 89.1%); hemoglobin, 7.6 gm/dL; platelet count, 455000/uL; NT-proBNP, 6776 pg/mL; PT, 143s (INR >10); blood urea nitrogen (BUN), 33 mg/dL; creatinine, 0.77 mg/dL; Na 131 mmol/L; K 2.5, mmol/L; Ca 8.4 mg/dL; Mg, 2.4 mg/dL; and albumin 1.7 g/dL. The thyroid function tests were normal. Artery gas analysis showed hypoxia (pH, 7.4; PCO2, 36.9 mm Hg; PO2, 75.7 mm Hg; HCO3, 23.4 mmol/L; SaO2, 95%). The elevated PT and INR suggested warfarin overdose. We prescribed VitK1 1 ample per-12h and transfused frozen fresh plasma 12 units per-day. Three days later, the PT was normalized, 21s (INR2.0)