Massive neonatal intracranial hemorrhage caused by bromadiolone

Abstract

Rationale:Bromadiolone, often called a super-warfarin, is a potent rodenticide with long half-life. Skin and mucosal bleeding is the most common clinical manifestations of its intoxication. Bromadiolone intoxications in adults and children have been reported, but this phenomenon is rarely seen in fetuses. This paper presents a case of neonate with massive intracranial hemorrhage mediated by bromadiolone intoxication, highlighting that the bromadiolone is potentially lethal to the fetus.Patient Concerns:The male neonate presented with poor respiratory effort, decreased muscle tone, and pallor at birth. He developed generalized seizures on day 1 of life. His mother suffered from bleeding of oral mucosa and the subsequent lab screening for toxicants showed a bromadiolone level of 126 ng/mL.Diagnoses:Laboratory tests revealed that prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT). A computed tomography (CT) of his head revealed a severe subdural hematoma, which lead to midline shift, bilateral intraventricular hemorrhage, and subarachnoid hemorrhage. Serum from cord blood was collected and screened for toxicants. The result returned with a bromadiolone level of 94 ng/mL.Interventions:The neonate was treated with vitamin K, fresh-frozen plasma, and red blood cells.Outcomes:His parents required termination of all treatments, and the neonate unfortunately died shortly after.Lessons:Through clinical experience from this case, we believe that bromadiolone can be passed down to the fetus via placenta. Neonatal intracranial hemorrhage caused by bromadiolone is rare but potentially lethal. Pregnant women should be informed of the serious side effects of bromadiolone and this poisonous reagent should be avoided in any period during pregnancy.

Convulsive status epilepticus as the initial presentation of superwarfarin poisoning: a case report

“…The superwarfarin family include 11 members, i.e., eight 4-hydroxycoumarin namely brodifacoum, bromadiolone, coumachlor, coumafuryl, coumatetralyl, difenacoum, difethialone, and flocoumafen, and three indandione namely chlorophacinone, diphacinone and pindone (8). The identification of some of the superwarfarin compounds in human blood and tissue samples is currently possible only in reference laboratories (1,9,10). Patients who have ingested superwarfarin usually present with unexplained bleeding.…”

Spontaneous subdural haematoma in a neonate requiring urgent surgical evacuation

“…At 10 weeks, bilateral craniotomies and membrane stripping performed, complicated by post-op tension pneumocephalus requiring percutaneous needle aspiration and then bilateral subduro-peritoneal shunts Seizures and severely abnormal neurological development Whitby et al [ 25 ] MRI performed within 48 h following 16 elective and 11 emergency CS in asymptomatic neonates N/A None had SDH N/A N/A N/A Usul et al [ 23 ] Case report of emergency CS following oblique presentation Posterior fossa Symptomatic None found Conservative Radiological resolution on follow-up imaging at 5 months Looney et al [ 12 ] MRI performed after 1–5 weeks of life following 23 CS in asymptomatic neonates N/A None had SDH N/A N/A N/A Powers et al [ 18 ] Case report of an uncomplicated CS Bilateral supratentorial Symptomatic VATER syndrome and macrocephaly - Serial unilateral percutaneous subdural taps - VPS for hydrocephalus - Represented with shunt infection and reaccumulation of subdural collection noted. Treated with external drainage and antibiotics - Required a subdural catheter to be connected to a new VPS 2 weeks later Normal neurological examination reported at 1 month of age (prior to insertion of first VPS) Rooks et al [ 20 ] MRI performed within 72 h of birth following 13 elective and 19 emergency CS in asymptomatic neonates All supratentorial 4 had SDH (1 after elective and 3 after emergency CS) All asymptomatic Elective case had macrosomia All emergency cases had prolonged labour and one required vacuum assistance Conservative All resolved by 4 weeks Tavil et al [ 22 ] Case series of 16 cases of peripartum intracranial haemorrhage in term newborns Unilateral supratentorial 1 had SDH after CS Symptomatic Coagulopathy VPS Major physical and cognitive disability Ma et al [ 13 ] Case report of elective CS performed due to maternal coagulopathy Unilateral supratentorial with IVH Symptomat...…”

Adherence to Long-Term Follow-Up of Patients with Life-Threatening, Inhaled Synthetic Cannabinoids-Associated Coagulopathy in Chicago

“…Secondly, the long half-life of superwarfarins in the human body, brodifacoum in particular, could have deleterious effects on pregnancy outcomes in poisoned women in childbearing age (13)(14)(15). It is well-established that 4-hydroxycoumarins cross the placenta readily and inhibit synthesis of vitamin K-dependent proteins in the liver and extrahepatic tissues of the fetus (16).…”

“…It is well-established that 4-hydroxycoumarins cross the placenta readily and inhibit synthesis of vitamin K-dependent proteins in the liver and extrahepatic tissues of the fetus (16). This, in turn, could lead to spontaneous abortion and embryopathy during the first trimester and CNS abnormalities, fatal hemorrhage and stillbirth at any stage during pregnancy (13)(14)(15)(16). In addition, safety of prolonged, off-label administration of daily pharmacologic doses (~100 mg) of oral VK 1 in pregnant women and their fetuses has not been established (17)(18)(19).…”