Case Report An unusual case of abdominal arterial thrombosis in a young woman using desmopressin E.J.M. Schrijver a, ⁎, W. Deenik b , H. Chon c , N. Koedam d , A.M.E. Spoelstra-de Man a a Tergooiziekenhuizen Hilversum, Department of Intensive Care, Van Riebeeckweg 212, 1213 XZ Hilversum, the Netherlands b Tergooiziekenhuizen Hilversum, Department of Internal Medicine, Van Riebeeckweg 212, 1213 XZ Hilversum, the Netherlands c Tergooiziekenhuizen Hilversum, Department of Clinical Chemistry, Van Riebeeckweg 212, 1213 XZ Hilversum, the Netherlands d Tergooiziekenhuizen Hilversum, Department of Surgery, Van Riebeeckweg 212, 1213 XZ Hilversum, the Netherlands abstract article info Article history: Received 2 September 2011 received in revised form 4 November 2011 accepted 17 November 2011 Available online 2 December 2011 Keywords: Desmopressin Arterial thrombosis We report an unusual case of severe abdominal arterial thrombosis in a young woman using oral desmopres- sin. Only a few cases with cerebrovascular accidents and coronary syndromes have been described so far, which could be attributed to intravenous administration of desmopressin. Because extensive diagnostic and laboratory investigations for (un)common coagulation disorders could not identify an alternative expla- nation associated with arterial thrombosis, we hypothesise that desmopressin in an oral dose of at least 200 ug once daily must have been sufficient to cause this dramatic vascular complication. Supportive of our hypothesis, we found remarkably high levels of factor VIII activity, Von Willebrand factor (vWF) antigen and vWF ristocetin cofactor activity (268%, 740%, 590% respectively). To the best of the authors' knowledge, this is the first report suggesting a relationship between oral desmopressin use and life-threatening abdom- inal arterial thrombosis. © 2011 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved. Introduction Desmopressin (1-deamino-8-D-arginine vasopressin, abbreviated DDAVP) is a synthetic vasopressin analogue (V2-receptor agonist). This drug is prescribed for the treatment of diabetes insipidus and nocturnal enuresis, because of its specific antidiuretic effect. Desmo- pressin stimulates the release of von Willebrand Factor (vWF) from vascular endothelial cells and raises plasma levels of factor VIII, here- by shortening the bleeding time, making it an effective drug to treat patients with coagulation disorders such as haemophilia A and von Willebrand disease (vWD) [1]. Case report A 27-year-old woman presented at the emergency room with a 7-week history of abdominal pain and diarrhoea. She was treated by her general practitioner for a Clostridium difficile-associated diarrhoea with metronidazole 500 mg orally three times daily for 10 days. Her medical history included borderline personality disorder with multiple auto-intoxications requiring hospital admission. Because of nocturnal enuresis, she was prescribed desmopressin 200 ug once daily since approximately 3 months next to aripiprazole, citalopram, alprazolam and topiramate. On physical examination her vital signs were normal. Abdominal examination revealed decreased bowel sounds with diffuse abdominal pain without muscular defence. Rectal examination was normal. Laboratory results included a sodium level of 132 mmol/L (137–144), a potassium level of 3.3 mmol/L (3.5–5.0), C-reactive pro- tein 180 mg/L (b 5.0), leukocyte count of 23.7×10 9 /L (4.0–11.0) with 10% of band-forms in the differential count, lactate 4.8 mmol/L (b 2.0) and a creatinine level of 47 umol/L (50–95). Coagulation tests were not performed in the emergency room. An abdominal CT scan showed an ileus of the small intestine with thickening of the jejunum. Gastros- copy showed severe reflux oesophagitis. She was admitted to hospital for observation. Because of clinical deterioration and an increase in plas- ma C-reactive protein and lactate, an exploratory laparotomy was per- formed the day after admission. Unexpectedly, this exploratory laparotomy revealed extensive small bowel ischaemia 30 cm distal to the ligament of Treitz until 50 cm proximal to the ileocoecal valve. Part of the left lobe of the liver appeared necrotic, as well as a part of the spleen. The colon and sigmoid were both well-perfused. The abdo- men was temporarily closed to perform a per-operative abdominal contrast-enhanced CT-scan, which showed occlusion of the coeliac trunk, hepatic artery, lineal artery, left gastric artery and superior mes- enteric artery (4 cm from its origin) (Fig. 1). A thrombectomy of these arteries was performed and therapeutic doses of unfractionated heparin were infused. Remarkably, thrombosis of the celiac trunk immediately recurred during the procedure, suggestive of a severe coagulation disor- der. An aortahepatic bypass was made and the majority of the small bowel was resected, leaving a residual small intestinal length of less than 100 cm. Clinical Biochemistry 45 (2012) 165–167 ⁎ Corresponding author. E-mail address: ejm.schrijver@gmail.com (E.J.M. Schrijver). 0009-9120/$ – see front matter © 2011 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.clinbiochem.2011.11.011 Contents lists available at SciVerse ScienceDirect Clinical Biochemistry journal homepage: www.elsevier.com/locate/clinbiochem