# A Case Report of Severe Bromadiolone Poisoning: Blood Toxicology Levels and Correlation to Clinical Toxicity

## TL;DR

A family in Singapore experienced severe poisoning from bromadiolone, a rodenticide, leading to life-threatening bleeding and requiring intensive treatment.

## Contribution

This case report provides insights into bromadiolone poisoning diagnosis and treatment in a low-incidence region.

## Key findings

- Bromadiolone levels in blood (up to 450 ng/mL) correlated with severe coagulopathy and clinical toxicity.
- Early recognition and vitamin K therapy were critical for recovery in this poisoning cluster.
- Blood testing is more effective than urine testing for bromadiolone due to its lipophilic nature and long half-life.

## Abstract

Bromadiolone is a long-acting anticoagulant rodenticide (“superwarfarin”) that can cause severe, prolonged coagulopathy. Its occurrence in Singapore is rare, with limited reported cases. We report a toxic cluster involving three household members with confirmed bromadiolone poisoning. The index patient, a 49-year-old woman, presented with abdominal pain, hematuria, and hemoperitoneum secondary to a ruptured corpus luteal cyst. Laboratory tests revealed profound coagulopathy (prothrombin time (PT) >180 s, international normalized ratio (INR) unmeasurable) with warfarin-like factor deficiencies. Serum bromadiolone level was 150 ng/mL; the other two household members had levels of 250 ng/mL and 450 ng/mL, respectively. The patient underwent surgical intervention, received intravenous vitamin K every six hours, blood product transfusions, and supportive therapy. She recovered fully after 10 days and was discharged on tapering oral vitamin K. This cluster highlights the diagnostic challenge of superwarfarin poisoning in the absence of a clear exposure history. Literature suggests toxicity can occur at serum bromadiolone levels as low as 117 ng/mL. Blood testing is preferred over urine due to bromadiolone’s high lipophilicity and long half-life. Early recognition, targeted toxicology testing, and prompt initiation of vitamin K therapy are essential. In regions with low incidence, superwarfarin poisoning should be suspected in patients with unexplained bleeding and markedly prolonged coagulation profiles. Cluster detection warrants urgent public health investigation to identify and control potential sources.