Rodenticide-Induced Coagulopathy in a Young Child: A Case of Munchausen Syndromeby Proxy

摘要

Many common rodenticides contains superwarfarins, such as brodifacoum, which arelong-acting anticoagulants. Like warfarins, superwarfarins induce a functional deficiency of the vitamin K-dependent clotting factors. Children with accidental ingestions are usually not symptomatic; hemorrhagic complications are more likely after large or multiple ingestions. This report describes the diagnosis and management of intentional rodenticide poisoning in a 24-month-old child with multiple bruises, a prolonged prothrombin time and activated partial thromboplastin time, and reduction of the vitamin K-dependent coagulation factors. The coagulopathy was treated successfully with large doses of parenteral and oral vitamin K; fresh-frozen plasma was administered as a precautionary measure on two occasions. Oral vitamin K was continued in tapering doses for 9 months, using the prothrombin time as a guide for therapy. After the first 10 days of the child's hospitalization, the mother was identified as the source of brodifacoum. During this time, she continued to feed her the rodenticide to induce coagulopathy, exemplifying the behavior described as Munchausen syndrome by proxy. This report emphasizes the necessity of recognizing rodenticide poisoning and investigating its source. Frequent monitoring of the prothrombin time is essential to prevent hemorrhagic complications due to repeat exposure, noncompliance, or inadequate therapy.