An 84-year-old woman presented to the emergency department with a bilateral cervical
hematoma and symptoms of upper-
airway obstruction that had been increasing for 72 hours, with
dyspnea and difficulty speaking developing in the previous 24 hours. Transnasal fiberoptic laryngoscopy revealed a significant laryngeal
hematoma, as well as a
hematoma on the floor of the mouth and in the tonsil area. Laboratory abnormalities included a prothrombin time < 10%, an international normalized ratio exceeding the laboratory limits, and an activated partial thromboplastin time >120 seconds. The patient had been receiving
acenocoumarol 4 mg/d for 10 years for episodes of
atrial fibrillation and recurrent
deep venous thrombosis. Seventeen days earlier, she had received a prescription for topical
econazole lotion 1% to be applied 3 times daily for 1 month to treat a
dermatitis affecting 12% of the body surface. The patient was admitted to the intensive care unit for treatment of
respiratory failure, where
oxygen was delivered by face mask. The coagulation disorders were treated with
prothrombin complex concentrate 30 IU/kg IV and
vitamin K1 10 mg IV, and values normalized within 36 hours. Surgical evacuation of the laryngeal
hematoma was not necessary. After 48 hours, improvement in the patient's respiratory symptoms allowed transfer to the ear, nose, and throat unit, where daily endoscopic examination was performed.
Aspirin was substituted for
acenocoumarol, and the patient returned home after 10 days without sequelae. Based on a Naranjo score of 7, this episode was probably related to an interaction between
acenocoumarol and
econazole.
CONCLUSION: