Major bleeding under enoxaparin treatment. An unexpected second offender

Admitted to hospital with an ischemic stroke, a 63-year-old male was diagnosed with a left ventricular mural thrombus. Enoxaparin treatment was started. Over 6 weeks there were two episodes of major hemorrhage needing brief discontinuation of anticoagulation. A previously normal prothrombin time (PT) became prolonged upon which vitamin K deficiency was diagnosed. The deficiency was caused by enteral feeding using a formula which did not contain the required daily dose of vitamin K. A triple message emerges from this observation: theneed for monitoring the PT in patients receiving enteral feeding, more so in those receiving anticoagulant along with enteral feeding, and the appeal to fortify feeding formulas with vitamin K.