(1173) From Clot Clearance to Articular Complications: Bilateral Hemarthroses After Fibrinolytic Therapy

Introduction: Tenecteplase (TNK), a recombinant fibrinolytic agent related to tissue plasminogen activator (tPA), is employed to dissolve clots in conditions such as ST-elevation myocardial infarctions (STEMI), ischemic strokes, and pulmonary embolism. Hemarthrosis, characterized by blood accumulation in joint spaces, is mostly attributed to traumatic causes but can also arise from non-traumatic conditions like bleeding disorders. Though previously documented with other fibrinolytics such as streptokinase and tPA, hemarthrosis has not been reported with TNK use.

Description: We present a unique case involving a 69-year-old male with a history of coronary artery disease and prior deep vein thrombosis (DVT), who was admitted with severe shortness of breath and syncope. Initial examination revealed hypotension, hypoxia, tachycardia, and elevated biomarkers including pro-BNP, troponin, and leukocytosis. Imaging confirmed a saddle pulmonary embolism with significant clot burden. Given his hemodynamic instability, TNK was administered in the emergency department (ED), leading to stabilization. However, 10 hours post-administration, the patient developed severe bilateral knee pain and swelling. Ultrasonography identified fluid accumulation in both knees, and bilateral knee aspiration revealed 250 milliliters (mL) of blood from the right knee and 150 mL from the left knee. Subsequent management included conservative measures followed by orthopedic consultation and arthrocentesis, which significantly alleviated symptoms and improved mobility. The patient was discharged to inpatient rehabilitation without further complications.

Discussion: Hemarthrosis is a rare side effect of fibrinolytic therapy, with no prior reports associated with TNK. The patient’s bilateral hemarthrosis highlights the potential for such adverse effects following TNK administration, necessitating vigilant monitoring for bleeding complications. Pre-existing joint disease may exacerbate this risk, and the inflammatory response to blood in the joint space can lead to joint damage and early-onset osteoarthritis. Conservative management includes compression, cooling, and pain control, with further intervention like arthrocentesis considered if conservative measures fail.