Role of prophylactic anticoagulation in acutely ill medical patients has been 
extensively probed with the development of guidelines which made it convenient 
for the physicians to adopt a particular anticoagulation regimen for 
thromboprophylaxis. Intermingled with the guidelines are the development of 
modern anticoagulants like direct factor Xa inhibitors which are being studied 
for their role in the prevention of venous thromboembolism (VTE) in medically 
ill patients and have been concluded so far with the positive note. We are going 
to discuss a case of a patient who was admitted in the medical ICU with hospital 
acquired pneumonia. As her immediate risk of VTE was low (Wells criteria), she 
was advised mechanical measures to prevent VTE along with continuation of 
rivaroxaban therapy which had already been prescribed for her avalvular atrial 
fibrillation. While mechanically ventilated, she developed pulmonary venous 
thromboembolism. It is the first case report of VTE in adequately anticoagulated 
patient with rivaroxaban.