The Case

After entering the room, it is clear something unusual is going on. This previously healthy 27-year-old has large blood-filled blisters in her mouth. In front of her, she carries a basin into which she is continuously spitting up blood, saliva, and clots.

She had presented to another emergency department two days earlier with complaints of hematuria and flank pain. After a negative CT scan of her abdomen and pelvis, she was given a provisional diagnosis of urinary tract infection and hematuria and discharged home with a prescription for nitrofurantoin. Apart from the recently prescribed antibiotic, she denies any other medications or supplements.

Her physical exam reveals a pale, ill-appearing, and uncomfortable female. Large hemorrhagic bullae fill her mouth, particularly around the gingiva and sides of the tongue. Cutaneous findings include scattered ecchymoses and an oozing abrasion on her right upper extremity. The rest of the physical exam is unremarkable.

Initial labs are normal other than a hemoglobin and hematocrit that are slightly elevated. Similarly, liver function tests are unremarkable. The coagulation study results are taking much longer than expected. A urine toxicology screen is negative for opioids, benzodiazepines, phencyclidine, and cannabis.

Additional social history reveals she smokes marijuana daily, but because she is trying to find employment, she recently switched to smoking synthetic cannabinoids (ie, “spice”) to avoid detection on pre-employment urine drug screens. She denies any other recreational drug use.

She reports that spice is sold under a variety of names in small sealed packets she buys from several corner markets throughout the city. The packaging varies, and she reports smoking multiple brands. Sometimes they are labeled as other substances such as Kratom, but the patient states it is a well-known fact these packages actually contain synthetic marijuana. The spice is clearly different from the regular marijuana she used to smoke. She noted a brief, more intense high and found herself smoking synthetic cannabinoids multiple times daily.

Finally, her coagulation results come in: Her activated partial thromboplastin time is 92 seconds, her prothrombin time (PT) is >120 seconds, and her international normalized ratio (INR) is >20. She is given four units of fresh frozen plasma (FFP) and 10 mg of IV vitamin K1.

Despite a negative past medical history or anticoagulant use, coumarin anticoagulant poisoning is suspected. Oral vitamin K1 (50 mg three times daily) is started, consistent with management from previous reports of intentional warfarin overdoses.¹