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Various toxicities: case report A 77-year-old man developed intra-bladder haemorrhage, haematoma and bladder rupture secondary to warfarin overdose and concurrent treatment with clarithromycin. Additionally, aspirin contributed to the intra-bladder haemorrhage [routes and duration of treatment to reactions onsets not stated; not all dosages stated]. The man presented to the emergency department with haematuria, abdominal pain and reduced urine volume since 3 days. He presented to hospital first time with this complaint. He reported that he had used clarithromycin 500mg tablet twice daily for acute pneumonia one week before. He had been receiving aspirin [Coraspin] 100mg, warfarin and inhaler (unspecified β2- mimetic) for coronary artery disease, arrhythmia, hypertension and chronic obstructive pulmonary disease. He did not have a recent history of surgery, bladder cancer or trauma. Physical examination showed he was oriented, co-operative and alert. His vital signs showed blood pressure 148/88, respiratory rate 20, oxygen saturation 94% on room air, pulse rate 92 and body temperature 36.6°C. Local bruises were observed on his arms and legs. The abdominal findings showed suprapubic tenderness to deep palpation in the bilateral lower quadrants. He underwent double vascular access, and a bladder Foley catheter was inserted. It was found that there was residual urine in the bladder and gross haematuria was noted. Based on this finding, presumptive diagnoses of urinary tract infection and acute renal failure were made. Focused assessment with sonography in trauma showed free fluid in retrovesical space. Urinary system ultrasound, abdominal CT, Posterior-anterior chest X-ray and abdominal X-ray did not show major findings of freeair or perforation with direct radiography. Cystography imaging revealed the possibility of blood accumulation due to bladder rupture to the intraperitoneal region. Laboratory investigations revealed he had gross haematuria. It was postulated that the combination of warfarin and clarithromycin increased the effect of warfarin that led to an intra-bladder haemorrhage and subsequent risk for bladder rupture. These results were attributed to warfarin overdose. He was treated with a slow infusion of vitamin K for 30 min. Ultrasonography showed haematoma in the bladder. An abdominal CT showed spontaneous bladder rupture secondary to warfarin overdose. He was started on prothrombin complex concentrate infusion over 45 min. Subsequently, he was scheduled for surgery with a preliminary diagnosis of bladder rupture following microscopic haematuria. During surgery, an organised haematoma was observed in the bladder and a perforation area of 2–3cm in the posterior wall of the bladder, which confirmed the diagnosis of intra-bladder haemorrhage. A catheter was inserted and the bladder mucosa muscles were closed separately and a primary repair was performed. Following repair, he did not have any unanticipated events. He was transferred to the ICU. His urine output was found to be increasing till the thir