Message from Massage - An Uncommon Complication of Oral Anti Coagulants

Introduction: Individualized Anticoagulants are used for stroke prevention in Atrial Fibrillation (AF) and Venous Thrombo Embolism (VTE) prophylaxis. Case Report: We had a Forty-Two-year old male patient who was admitted with history of exertional breathing difficult. Also had pain, swelling and tenderness of bilateral anterior thigh region. Local Ultra Sound examination reported hematoma and hemarthrosis. He was on treatment for Type 2 DM, HTN, Paroxysmal AF and Post DVR (2016) and Redo MVR (2018) with Oral Anti Coagulation (OAC) along with other routine medications. These acute symptoms occurred following self-advised bilateral lower limb massage for myalgia. His preliminary investigation revealed Severe Anemia (Hb - 3.8gms/dl) and INR of > 10. Received 3 units of compatible blood transfusions, IV Vitamin K injections and other routine medications. Hb improved to 9.4 gms/dl. 2D Echocardiography although initially showed increased gradients across prosthetic valves improved after blood transfusions. Symptoms gradually stabilized and discharged with stable hemodynamic conditions. Discussion: Clinicians face increasingly complex decisions relating to appropriate agent, duration of treatment and use in special populations. Newer OACs, like Dabigatran (oral Factor Xa inhibitor) neither requires regular laboratory monitoring nor affected by external factors.