Garrett S. Booth

To the Editor: Tullius and Rabb (May 17 issue)¹ thoroughly describe current evidence regarding strategies to reduce the gap between the demand and supply of organs for transplantation. We also think it is relevant to discuss the importance of legislation on consent during a person’s lifetime for organ donation after death. Whereas many countries, including the United States, have an opt-in system in which the donation of organs from deceased persons requires specific consent, other countries have adopted an opt-out system, which is also known as presumed consent. The opt-out system considers deceased persons to be potential donors in the . . .

Exposure to brodifacoum, a superwarfarin substance, can lead to severe coagulopathic manifestations. Brodifacoum is a lipophilic, vitamin K antagonist with a long half-life. Clinical manifestations are challenging to diagnose if the patient cannot provide information regarding exposure. Herein, we report the first case in the literature, to our knowledge, of a patient who had intentionally inhaled brodifacoum. We performed coagulation studies such as prothrombin time (PT) and international normalized ratio (INR) to monitor vitamin K dependent coagulation factors in the patient, a 21-year-old Caucasian man. On admission to the hospital, the INR of the patient was 12.9; a computed tomography (CT) angiogram detected a mediastinal hemorrhage. In the absence of 4-factor PCC, the patient received 30 plasma transfusions during a 4-day period due to persistent left pleural effusions, along with vitamin K therapy to normalize his coagulation factors. His high-performance liquid chromatography (HPLC) results on hospital day 3 and day 26 confirmed the presence of brodifacoum in his body. We believe that inhalation led the poison to bypass the initial metabolism process of the liver, resulting in rapid anticoagulation and subsequent bleeding diathesis. Management of brodifacoum poisoning is case dependent on the amount of exposure and INR status. Constant INR monitoring, large dose vitamin K therapy and initial plasma transfusions (in the absence of PCC) were able to prevent severe internal bleeding in the patient.

Amyloidosis is a progressive disease that traditionally is associated with poor clinical outcomes. Recent advances in amyloidosis treatment may allow for more patients tobe considered for autologous stem cell transplantation. In this report, we review a case of autologous peripheral blood stem cell transplantation in a patient with systemic amyloidosis and review special considerations in peripheral blood stem cell collection in such patients. We conclude that it may be reasonable to consider substituting heparin for some of the citrate used in peripheral blood stem cell collection procedures performed on patients with cardiac amyloidosis, so long as there are no contraindications to heparin exposure.