EYM CHUNG1, J CHEN1, S ROXBURGH1
1Royal North Shore Hospital, Sydney, New South Wales
Background: Rivaroxaban is an anti-factor Xa direct oral anticoagulant which is widely used in the treatment of venous thromboembolism due to the ease of use and non-inferiority to warfarin. Leukocytoclastic vasculitis associated with rivaroxaban has been reported in only two previous cases but neither case had associated features of systemic vasculitis or proteinuria suggestive of glomerulonephritis.
Case Report: A 45-year old man received rivaroxaban treatment for unprovoked pulmonary emboli and right leg deep venous thrombosis. Within 14 days of commencing rivaroxaban, he developed a non-blanching purpuric rash, nephrotic range proteinuria (4.1g in 24 hours), bilateral pitting lower limb oedema, bilateral flank pain, and constitutional symptoms (night sweats, myalgias, and arthralgias). Skin biopsies showed leukocytoclastic vasculitis. Renal biopsy showed mildly increased mesangial matrix and rare hypercellularity, plus strong granular mesangial staining for IgA on immunofluorescence, consistent with a diagnosis of IgA nephropathy.
Conclusions: To our knowledge, this is the first reported case of IgA nephropathy and Henoch-Schonlein purpura associated with rivaroxaban, and highlights the first potential renal parenchymal adverse effect of rivaroxaban. Clinicians should be aware that cutaneous adverse effects are not limited to leukocytoclastic vasculitis but may represent Henoch-Schonlein purpura/IgA nephropathy.