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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.

Major bleeding under enoxaparin treatment. An unexpected second offender