A 56-year-old woman with end-stage renal disease (ESRD) on hemodialysis (HD) was diagnosed with upper extremity deep vein thrombosis (DVT) one month prior to presentation and started on apixaban presented with dyspnea and left-sided pleuritic chest pain for two weeks that have been progressing slowly. She denied any other respiratory symptoms such as hemoptysis and cough and had no history of falls nor trauma. There was no weight loss, fever, night sweats, or recent travels. She has history of hypertension, diabetes mellitus, and prosthetic mitral valve replacement and she takes lisinopril, carvedilol simvastatin, and aspirin. Physical examination revealed tachypnea and dullness to percussion of the posterior left hemithorax along with decrease in tactile fremitus; she remained hemodynamically stable throughout her hospital stay. Laboratory tests on admission revealed the following: prothrombin time (PT) of 11.5 seconds, international normalized ratio (INR) of 1.03, activated partial thromboplastin time (aPTT) of 30.4 seconds, and hemoglobin of 7.0 g/dL. Chest radiograph (CXR) showed opacification of two-thirds of the left hemithorax with tracheal deviation to the contralateral side consistent with pleural effusion (Figure 1). Bedside ultrasound of left hemithorax revealed hypoechoic fluid without loculations. Even though she was transfused one unit of packed red blood cells (PRBC), her Hb dropped to 6.7 g/dL on the second day of admission.
Apixaban was held for 48 hours and bedside ultrasound-guided thoracentesis was performed on the third day of admission. One liter of bloody fluid was drained and sent for testing (Figure 2). Pleural fluid analysis was as follows: hematocrit (Hct) 22%, red blood cells (RBC) 126,000/mm3, white blood cells (WBC) 1,400/mm3; bacterial gram-stain, culture, and acid-fast bacilli smear were negative for bacteria and tuberculosis, respectively, and cytology negative for malignant cells. Serum Hct was 25% at the time of the thoracentesis. The finding of pleural fluid analysis was consistent with hemothorax (pleural Hct to serum Hct ratio 88%). A chest computed tomography (CT) with intravenous contrast was done to rule out active bleeding, vascular malformations, and other causes of spontaneous hemothorax (Figure 3).
A 12-Fr pigtail catheter was inserted and another one liter was drained in the first 2 hours which then slowed down to 300ml in the next 24 hours and afterwards 20-30ml daily for 2 days. CXR after drainage showed near-total resolution of the pleural effusion (Figure 4). The catheter was then removed and patient was discharged without complications.