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Zakar R, Saad N, El Tannoury M, El Tannoury B, Ismail MA, Riachy M, Karam L. Heparin-Induced Hemorrhagic Bullous Dermatosis: A Rare Complication of Unfractionated Heparin. Cureus 2024; 16:e63676. [PMID: 38957518 PMCID: PMC11219031 DOI: 10.7759/cureus.63676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 07/04/2024] Open
Abstract
We present a case of an 82-year-old female with a significant medical history of hypertension and Alzheimer's disease who developed heparin-induced hemorrhagic bullous dermatosis during treatment for a subsegmental pulmonary embolism. The patient was admitted with lower extremity edema and cyanosis, diagnosed with a subsegmental pulmonary embolism, and started on therapeutic doses of unfractionated heparin. On the sixth day of heparin therapy, she developed abdominal bloating and a diffuse exanthematous rash, which progressed to hemorrhagic bullae on the plantar and dorsal aspects of her feet, alongside extensive purpura on her legs. Laboratory findings revealed thrombocytopenia. Multidisciplinary consultations confirmed the diagnosis of heparin-induced hemorrhagic bullous dermatosis. Management included continuing unfractionated heparin with close monitoring, supportive topical treatments, and a subsequent transition to rivaroxaban. The patient's condition improved significantly, and she was discharged in stable condition. This case highlights the importance of recognizing rare adverse reactions to heparin and raises the question of preventive measures or risk factors related to this manifestation.
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Affiliation(s)
- Rida Zakar
- Medical School, Université Saint Joseph, Beirut, LBN
| | - Nader Saad
- Thoracic and Vascular Surgery, Hôtel-Dieu de France, Beirut, LBN
| | - Marie El Tannoury
- Pulmonary and Critical Care Medicine, Hôtel-Dieu de France, Beirut, LBN
| | - Boutros El Tannoury
- Orthopaedic Surgery, Centre Hospitalier Universitaire Notre Dame Des Secours, Holy Spirit University of Kaslik, Kaslik, LBN
| | | | - Moussa Riachy
- Pulmonary and Critical Care Medicine, Hôtel-Dieu de France, Beirut, LBN
| | - Lamisse Karam
- Thoracic and Vascular Surgery, Hôtel-Dieu de France, Beirut, LBN
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Cortez de Almeida RF, Vita Campos C, Daxbacher EL, Jeunon T. Heparin-Induced Bullous Hemorrhagic Dermatosis: A Report of an Exceptionally Exuberant Case and Literature Review. Am J Dermatopathol 2021; 43:497-505. [PMID: 33795557 DOI: 10.1097/dad.0000000000001787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Heparin-induced bullous hemorrhagic dermatosis (HBHD) is an unusual cutaneous adverse reaction to heparin characterized by acute onset of hemorrhagic bullae. METHODOLOGY An exuberant case of HBHD is reported, and a revision of previously reported cases indexed on PubMed is provided. Cases were tabulated to the following parameters: sex, age, type of heparin and route of administration, associated medical procedure, number of days between heparin start and onset of lesions, site of the lesions, level of blister on histopathology, inflammatory infiltrate on histopathology, direct immunofluorescence findings, heparin-related intervention, number of days to resolution of skin lesions, associated hemorrhagic event, and outcome. CASE REPORT A 21-year-old woman with end-stage renal disease was receiving intravenous unfractioned heparin (UFH) during hemodialysis section for the past 3 months. Four hours after using for the first time an arteriovenous fistula punctured on her right wrist, the patient noticed the onset of vesicles and blisters on the right forearm containing citrus or serohemorrhagic exudate, which became overt hemorrhagic in 24 hours. Histopathology depicted a nonacantholytic subcorneal blister containing erythrocytes and plasma without any significant dermal inflammatory infiltrate. RESULTS Sixty cases of HBHD were included. HBHD affected predominantly men, with a male/female rate of 2.75. The age range was from 21 to 94 years, with an average of 70.8 and a median of 72 years. Nine patients used UFH, and 54 patients used low molecular weight heparins (3 patients used both). The lapse of time between the start of heparin and the onset of skin lesion varied from 6 hours to 240 days, with an average of 17.3 days and a median of 7 days. Limbs were affected in most of the cases. The level of the blister was subcorneal in 10 patients, intraepidermal in 30, subepidermal in 8, and both intraepidermal and subepidermal in 1. In 33 cases, there was no significant dermal inflammatory infiltrate. Pure lymphocytic inflammatory infiltrate was present in 10 cases. Eosinophils were found within the dermal inflammatory infiltrate in 2 cases, neutrophils in 2, and a mixture of eosinophils and neutrophils in other 2. Direct immunofluorescence was performed in 18 cases, all of them with negative results. DISCUSSION We hypothesize that mechanical trauma, skin fragility, and the anticoagulation effect of heparin might contribute concomitantly to the development of the lesions and speculate that subepidermal blisters in HBHD could be formed by rupture of the floor of a former intraepidermal blister.
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Affiliation(s)
| | - Clarissa Vita Campos
- Dermatology Department, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil ; and
| | - Egon Luiz Daxbacher
- Dermatology Department, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil ; and
| | - Thiago Jeunon
- Dermatology Department, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil ; and
- ID- Investigação em Dermatologia, Rio de Janeiro, Brazil
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Martin MU, Lambert A, Miremont G, Gaiffe A, Agier MS, Studer M, Mahé A, Tebacher M, Cribier B. Bullous haemorrhagic dermatitis induced by heparins and other anticoagulants: 94 cases from French pharmacovigilance centres and a literature review. Ann Dermatol Venereol 2021; 149:45-50. [PMID: 34175142 DOI: 10.1016/j.annder.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/17/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bullous haemorrhagic dermatitis (BHD) is an uncommon and highly particular side effect of various forms of heparins. METHODS To better characterise the disease, we collected all cases from French Pharmacovigilance centres recorded over a 20-year period (37 cases) and performed a Medline literature search up to June 2020 (57 cases). RESULTS In all, 94 patients were identified (male/female ratio: 2.2) of mean age 73.5±12.1 years (31-94). Patients were treated with enoxaparin (n=66), unfractionated heparin (n=11), fondaparinux (n=10), tinzaparin (n=4), bemiparin (n=1), reviparin (n=1), dalteparin (n=1), and 4 with other anticoagulants: warfarin (n=3) and rivaroxaban (n=1). All cases presented with 1 to more than 100 haemorrhagic vesicles and bullae, distant from the injection sites, located mainly on the lower (75%) or upper limbs (69%). The lesions were asymptomatic, except in 5 patients who had pruritic or painful lesions. The interval between treatment initiation and BHD ranged from 6 hours to 30 days (mean: 8.4±7 days). Biopsy (n=53) showed intraepidermal or subcorneal cavity with red cells (n=39) or junctional blisters (n=10), with eosinophilic infiltrate only rarely. Direct immuno-fluorescence was negative in 19/20 cases and indirect immunofluorescence was negative in 8/8. The outcome was favourable in all cases, including in 12 patients for whom heparin was maintained. A 93-year-old patient died of compressive haematomas unrelated to BHD. We found 5 cases similar to BHD due to other anticoagulants. DISCUSSION This is the largest comprehensive series of this adverse effect due to heparins or, more rarely, to other anticoagulants. Dermatologists must be aware of BHD, since this benign side effect does not necessarily require interruption of treatment. It is rare, considering the large-scale prescription of heparins, and occurs mainly in male patients aged over 70. Although the presentation is highly typical, the physiopathology is difficult to understand, as coagulation parameters are usually normal. Aging, skin fragility or mechanical factors might play a role.
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Affiliation(s)
- M-U Martin
- Centre régional de pharmacovigilance de Strasbourg, HUS, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - A Lambert
- Centre régional de pharmacovigilance de Strasbourg, HUS, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - G Miremont
- Pôle de santé publique, pharmacologie médicale, centre de pharmacovigilance de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - A Gaiffe
- Centre régional de pharmacovigilance de Besançon, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - M-S Agier
- Centre régional de pharmacovigilance de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - M Studer
- Service de dermatologie, centre hospitalier de Colmar, 39, avenue de la Liberté, 68000 Colmar, France
| | - A Mahé
- Service de dermatologie, centre hospitalier de Colmar, 39, avenue de la Liberté, 68000 Colmar, France
| | - M Tebacher
- Centre régional de pharmacovigilance de Strasbourg, HUS, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - B Cribier
- Clinique dermatologique, hôpitaux universitaires et université de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
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Russo A, Curtis S, Balbuena-Merle R, Wadia R, Wong E, Chao HH. Bullous hemorrhagic dermatosis is an under-recognized side effect of full dose low-molecular weight heparin: a case report and review of the literature. Exp Hematol Oncol 2018; 7:15. [PMID: 29989046 PMCID: PMC6035443 DOI: 10.1186/s40164-018-0108-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 06/28/2018] [Indexed: 11/24/2022] Open
Abstract
Bullous hemorrhagic dermatosis (BHD) is a systemic side-effect of low molecular weight heparin, characterized by multiple intra-epidermal hemorrhages distant from the site of injection. There have been several small case series and literature reviews on BHD, but none have captured a complete set of reported patients. We sought to describe a case of BHD with late diagnosis and completely summarize the existing English and Spanish literature with searches of Pubmed, Scopus, Ovid Embase and Ovid Medline. After narrowing to 33 relevant reports, we describe 90 reported cases worldwide from 2004 to 2017, in addition to a new case from our institution as a means of comparison. We found that BHD was common in elderly men (mean age 72 ± 12; male:female, 1.9:1) and typically occurred within 7 days of administration of anticoagulation (median 7 days ± 6.4) usually with enoxaparin use (66% of cases). Lesions occurred primarily on the extremities only (67.9% of cases). Coagulation testing was most often normal before administration, and the majority of patients had coagulation testing in therapeutic range during treatment. Most practitioners stopped anticoagulation if continued therapeutic intervention was no longer required (57% of cases), or changed therapy to another anticoagulation if continued treatment was required (14.3% of cases). Therapy was continued outright in 23% of patients. The lesions usually resolved within 2 weeks (mean days, 13.0 ± 7.4). There was no difference in time to resolution between patients who continued the culprit anticoagulant or changed to a different anticoagulant, and those who discontinued anticoagulation altogether (13.9 days vs. 12.1, p = 0.49). Four deaths have been reported in this clinical context, two specified as intracranial hemorrhage. These deaths were unrelated to the occurrence of BHD. Continuation of low-molecular weight heparins appeared to be safe in patients with BHD.
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Affiliation(s)
- Armand Russo
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
| | - Susanna Curtis
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
| | - Raisa Balbuena-Merle
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT 06511 USA
| | - Roxanne Wadia
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
- VA Connecticut Healthcare System, Cancer Center, 950 Campbell Avenue, Mailcode 111D, West Haven, CT 06516 USA
| | - Ellice Wong
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
- VA Connecticut Healthcare System, Cancer Center, 950 Campbell Avenue, Mailcode 111D, West Haven, CT 06516 USA
| | - Herta H. Chao
- Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT 06511 USA
- VA Connecticut Healthcare System, Cancer Center, 950 Campbell Avenue, Mailcode 111D, West Haven, CT 06516 USA
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Shim JS, Chung SJ, Kim BK, Kim SH, Lee KS, Yoon YE, Chang YS. Bullous hemorrhagic dermatosis due to enoxaparin use in a bullous pemphigoid patient. Asia Pac Allergy 2017; 7:97-101. [PMID: 28487841 PMCID: PMC5410417 DOI: 10.5415/apallergy.2017.7.2.97] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/25/2017] [Indexed: 12/04/2022] Open
Abstract
Adverse reactions of subcutaneous low molecular weight heparin or unfractionated heparin could be complications by bleeding, heparin-induced thrombocytopenia, drug-induced liver injury, osteoporosis, and cutaneous reactions. Heparin-induced skin lesions vary from allergic reactions like erythema, urticaria, eczema to intradermal microvascular thrombosis associated with heparin-induced thrombocytopenia. There is a rare cutaneous complication, called bullous hemorrhagic dermatosis. We experienced this rare case of the cutaneous complication caused by enoxaparin. Several tense bullous hemorrhagic lesions occurred after 3 days of enoxaparin in a known bullous pemphigoid patient who had aortic valve replacement surgery with a mechanical prosthesis. The bullous hemorrhagic lesions were regressed after the discontinuation of enoxaparin but recurred after re-administration. The lesions were controlled by the administration of systemic corticosteroid and alternative anticoagulant. To date, less than 20 cases have been reported worldwide. This is the first case of bullous hemorrhagic dermatosis induced by enoxaparin, a low-molecular-weight heparin in Korea. This is also the first case of bullous hemorrhagic dermatosis in a known bullous pemphigoid patient.
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Affiliation(s)
- Ji-Su Shim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.,Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| | - Soo Jie Chung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.,Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| | - Byung-Keun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.,Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.,Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Kyu Sang Lee
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.,Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea
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