Massive Spontaneous Haemothorax after Rivaroxaban Therapy for Acute Pulmonary Embolism

Spontaneous haemothorax complicating the treatment of pulmonary embolism is rare and potentially fatal. We describe a patient with pulmonary embolism and severe pleuritic pain who developed a life-threatening haemothorax 10 days later while on rivaroxaban therapy. This case highlights the fact that severe pleuritic pain associated with pulmonary embolism may indicate subclinical infarction of tissue near the visceral pleura with an increased risk of pleural effusion and the subsequent development of a haemothorax. It is important to recognise such danger signs warranting closer attention, especially since the increased use of direct oral anticoagulants has facilitated ambulatory care and this complication may manifest in the outpatient setting. LEARNING POINTS: Spontaneous haemothorax may occur in the first 2 weeks after a patient starts anticoagulation. Severe pleuritic pain in a patient with pulmonary embolism may indicate subclinical infarction near the visceral pleura with an increased risk of pleural effusion and the subsequent development of a spontaneous haemothorax. Patients with severe pain and pleural effusion should be monitored closely, especially if they are outpatients, even though initial radiological findings are not significant.