Rare manifestation of Bromadiolone toxicity as intracranial hemorrhage

Abstract Superwarfarins are second generation anticoagulants that work as highly potent vitamin K antagonist, used in many chemical poisons as rodenticide. Superwarfarins currently constitute variety of examples like Brodifacoum, Difenacoum, Bromadiolone, and Flocoumafen. With the increase usage of these compounds a lot of poisoning cases has been reported worldwide, most of these poisoning cases occur either by accidental exposure or suicidal attempts. Poisoning routes are inhalational, trans-cutaneous and oral routes. Most of the cases present clinically with skin bleeding, hematuria, epistaxis, digestive tract bleeding, and rarely intracranial bleeding. We report a 49-year-old man with a Bromadiolone poisoning that led to massive intracranial hemorrhage and treated for several months with vitamin K1 agonist. His first clinical presentation was altered level of consciousness, right sided Hemiplegia, left sided hemiparesis, headache, and recurrent vomiting, with history of gross hematuria, hematochezia, and epistaxis, which had been persistent over the last 10 days prior to his presentation. On physical examination Glasgow Coma Scale (GCS) was 14/15 (confused), cranial nerves were intact except flatten right nasolabial fold and mild mouth drop, deep Tendon reflexes were brisk reflexes (+3) all over, power showed right sided hemiplegia (0/5), and left sided hemiparesis (4/5). Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), and the International Normalized Ratio (INR) was prolonged and high, respectively. In conclusion, Superwarfarin toxicity should be suspected in cases of unknown etiology of coagulopathy, with increased INR of more than six and increased coagulation profile time PT, and aPTT which is not responding to FFP treatment.