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AlQhtani A, AlSahabi A, Ashammery A. Warfarin-induced major unilateral breast necrosis in a patient with antiphospholipid syndrome: A case report. Int J Surg Case Rep 2020; 77:656-659. [PMID: 33395867 PMCID: PMC7708858 DOI: 10.1016/j.ijscr.2020.11.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 11/27/2022] Open
Abstract
Warfarin rarely causes necrosis, and antiphospholipid syndrome is a rarer cause of skin necrosis. Physicians should consider both conditions in the aetiology of skin necrosis. Management should involve stopping warfarin treatment, administering alternative medications, taking a good history, and performing proper examination, investigation, and wound management with dressings or operation using a multidisciplinary team. Wound management depends on the patient’s medical condition and considers the reconstructive ladder.
Introduction Warfarin-induced necrosis is a rare complication associated with the use of warfarin in addition to antiphospholipid syndrome. Case presentation A 50-year-old female patient with a known case of antiphospholipid syndrome started warfarin treatment for ischaemic changes in her toes and subsequently experienced warfarin-induced necrosis in her left breast. Then, warfarin treatment was suspended, and she was started on enoxaparin. Debridement was performed, and a skin graft was applied without complications. Discussion Skin necrosis has many differential diagnoses, and physicians must take a proper history and perform a physical examination with proper investigations involving a multidisciplinary team, including plastic surgery, haematology, internal medicine, and wound care specialists. Plastic surgery offers many options for reconstruction depending on the patient’s medical condition, the size of the wound and the location following the reconstructive ladder. Conclusion This case report presents a rare complication of warfarin in the context of antiphospholipid syndrome and describes the management of unilateral breast necrosis. Physicians should be highly suspicious of this condition in patients with skin necrosis who were administered warfarin or have antiphospholipid syndrome.
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Affiliation(s)
- Abdullh AlQhtani
- Plastic Surgery, General Surgery Department, College of Medicine, Prince Sattam Bin Abdulaziz University, Al Kharj, Saudi Arabia.
| | - Abdulrahman AlSahabi
- Plastic Surgery Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahmad Ashammery
- Plastic Surgery Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Sklar LR, Messman A. An Atypical Case of Warfarin-Induced Skin Necrosis. Clin Pract Cases Emerg Med 2017; 1:359-361. [PMID: 29849320 PMCID: PMC5965214 DOI: 10.5811/cpcem.2017.3.33373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/08/2017] [Accepted: 03/30/2017] [Indexed: 11/11/2022] Open
Abstract
Skin necrosis is a relatively rare, potentially fatal side effect of warfarin. It is most commonly reported within 10 days of initiation of therapy in warfarin-naïve patients. We report an atypical case of warfarin-induced skin necrosis upon recommencement of warfarin in a non-naïve warfarin patient.
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Affiliation(s)
- Lindsay R Sklar
- Wayne State University, Department of Dermatology, Dearborn, Michigan
| | - Anne Messman
- Sinai-Grace Hospital, Department of Emergency Medicine, Detroit, Michigan
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Lai J, Ramai D, Alchi R, Bloomfield D. Anticoagulation therapy for thromboembolism prevention: a case of warfarin-induced skin necrosis in the setting of protein C deficiency. BMJ Case Rep 2017; 2017:bcr-2016-218015. [PMID: 28500260 DOI: 10.1136/bcr-2016-218015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Patients with protein C deficiency are at increased risk for thrombolic diseases. Non-vitamin K antagonist anticoagulant options should be considered in patients with warfarin-induced skin necrosis (WISN) in the setting of protein C. We report a 41-year-old African American male patient with WISN and protein C deficiency who was treated with rivaroxaban followed by dabigatran. After 1 month on rivaroxaban, he began experiencing blood in his stools, unrelenting pain in his lower extremities, found it difficult to obtain medication despite having insurance and as a result did not maintain compliance. He was then assessed at the hospital, symptomatically treated and discharged on dabigatran. After 6 weeks, he reported symptomatic relief and less side effects. This case involved a head-to-head clinical comparison of rivaroxaban and dabigatran as alternatives to warfarin anticoagulation therapy.
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Affiliation(s)
- Jonathan Lai
- Department of Anatomical Sciences, St. George's University School of Medicine, True Blue, Grenada
| | - Daryl Ramai
- Department of Anatomical Sciences, St. George's University School of Medicine, True Blue, Grenada
| | - Ramiz Alchi
- Department of Medicine, Richmond University Medical Center, Staten Island, New York, USA
| | - Dennis Bloomfield
- Department of Medicine, Richmond University Medical Center, Staten Island, New York, USA
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Malik U, Liu J, Marquez F, Juarez K, Mayasy S. Atypical late-onset warfarin-induced skin necrosis with renal involvement. Thromb Haemost 2017; 117:639-641. [PMID: 27929202 DOI: 10.1160/th16-08-0646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/10/2016] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | - Shadi Mayasy
- Dr. Shadi Mayasy, University of New Mexico School of Medicine, Department of Internal Medicine, MSC10 5550, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA, Tel.: +1 505 272 4661, Fax: +1 505 272 4628, E-mail:
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Coagulation disorders and their cutaneous presentations: Diagnostic work-up and treatment. J Am Acad Dermatol 2016; 74:795-804; quiz 805-6. [DOI: 10.1016/j.jaad.2015.08.071] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 08/19/2015] [Accepted: 08/19/2015] [Indexed: 11/22/2022]
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Kakagia DD, Papanas N, Karadimas E, Polychronidis A. Warfarin-induced skin necrosis. Ann Dermatol 2014; 61:325-32. [PMID: 19615543 DOI: 10.1016/j.jaad.2008.12.039] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 12/11/2008] [Accepted: 12/23/2008] [Indexed: 02/07/2023] Open
Abstract
Warfarin-induced skin necrosis is an infrequent complication occurring in individuals under warfarin treatment who have a thrombophilic history or after administration of large loading doses of warfarin particularly without simultaneous initial use of heparin. A 62-year-old lady developed skin necrosis 4 days after initiating warfarin therapy of 5 mg daily without initial co-administration of heparin. The patient had a normal clotting profile. Skin necrosis progressed to eschar formation after cessation of warfarin and heparinization stopped expanding. Warfarin was reintroduced at 2 mg daily, initially together with low molecular weight heparin. Autolytic debridement of the necrotic tissue was followed by healing of the cutaneous deficit by secondary intention. Prompt diagnosis and discontinuation of warfarin are crucial for the prognosis.
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Affiliation(s)
- Despoina D Kakagia
- Department of Surgery-Plastic Surgery, Democritus University of Thrace, Alexandoupolis, Greece
| | - Nikolaos Papanas
- Department of Internal Medicine, Democritus University of Thrace, Alexandoupolis, Greece
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Beqqal K, Horellou MH, Philippe A, Alhene Gelas M, Flaujac C, Gorin I, Jacobelli S, Dupin N, Hassam B, Avril MF. Skin necrosis due to fluindione treatment: a rare but serious complication. J Wound Care 2014; 23:S16-9. [PMID: 24526169 DOI: 10.12968/jowc.2014.23.sup2b.s16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In the setting of protein C deficiency, skin necrosis, which occurs most often at the initial phase of oral anticoagulants therapy, is a rare side effect. Six cases have previously been reported in the literature. In this case report, we present a protein C deficient 42-year-old woman who was being treated for venous thrombosis. Five days after the initiation of oral anticoagulant treatment, she developed extensive skin necrosis on her left calf, followed by a painful leg ulcer. The pathogenesis underlying skin necrosis caused by anticoagulation therapy is still not clear. Despite only a few cases being reported in the literature, it is important to recognise this complication since adequate therapeutic approaches leading to a stable anticoagulation state may prevent it.
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Affiliation(s)
- K Beqqal
- MD, Dermatologist, APHP, Department of Dermatology, Hospital Cochin, Paris Descartes University, Paris, France, Department of Dermatology, Ibn Sina Hospital, University of Mohammed V-Souissi, Rabat, Morocco
| | - M H Horellou
- MD, Biologist, APHP, Department of Haematology and Biology, Cochin Hospital, Paris Descartes University, Paris, France
| | - A Philippe
- Nurse, APHP, Department of Dermatology, Hospital Cochin, Paris Descartes University, Paris, France
| | - M Alhene Gelas
- MD, Geneticist, APHP, Department of Haematology and Biology, Georges Pompidou European Hospital, Paris, France
| | - C Flaujac
- MD, Biologist, APHP, Department of Haematology and Biology, Cochin Hospital, Paris Descartes University, Paris, France
| | - I Gorin
- MD, Dermatologist, APHP, Department of Dermatology, Hospital Cochin, Paris Descartes University, Paris, France
| | - S Jacobelli
- MD, Dermatologist, APHP, Department of Dermatology, Hospital Cochin, Paris Descartes University, Paris, France
| | - N Dupin
- MD, APHP, Department of Dermatology, Hospital Cochin, Paris Descartes University, Paris, France
| | - B Hassam
- MD, Dermatologist, Department of Dermatology, Ibn Sina Hospital, University of Mohammed V-Souissi, Rabat, Morocco
| | - M F Avril
- MD, APHP, Department of Dermatology, Hospital Cochin, Paris Descartes University, Paris, France
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Tillou X, Ait-Said K, Collon S, Legal S, Desmonts A, Bensadoun H, Doerfler A. Unusual case of extensive warfarin-induced necrosis in an 84-year-old. J Am Geriatr Soc 2014; 61:2255-2257. [PMID: 24329839 DOI: 10.1111/jgs.12560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Xavier Tillou
- Urology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Khalifa Ait-Said
- Urology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Sylvie Collon
- Orthopedic Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Sophie Legal
- Urology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Alexis Desmonts
- Urology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Henri Bensadoun
- Urology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Arnaud Doerfler
- Urology Department, Centre Hospitalier Universitaire de Caen, Caen, France
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Hermans C, Eeckhoudt S, Lambert C. Dabigatran etexilate (Pradaxa®) for preventing warfarin-induced skin necrosis in a patient with severe protein C deficiency. Thromb Haemost 2012; 107:1189-91. [PMID: 22398431 DOI: 10.1160/th11-11-0788] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 02/21/2012] [Indexed: 12/16/2022]
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Abstract
Skin ulceration is a major source of morbidity and is often difficult to manage. Ulcers caused by an inflammatory cause or microvascular occlusion are particularly challenging in terms of diagnosis and treatment. The management of such ulcers requires careful assessment of associated systemic conditions and a thorough analysis of the ulcer's clinical and histologic findings. In this article, the authors discuss several examples of inflammatory ulcers and the approach to the diagnosis and treatment of these ulcers.
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Affiliation(s)
- Jaymie Panuncialman
- Department of Dermatology, Roger Williams Medical Center, 50 Maude Street, Providence, RI 02908, USA
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12
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Man With Painful Skin Lesion. Ann Emerg Med 2010; 55:302, 305. [DOI: 10.1016/j.annemergmed.2009.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 05/18/2009] [Accepted: 06/15/2009] [Indexed: 11/24/2022]
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13
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An unusual case of warfarin-induced pinna skin necrosis. The Journal of Laryngology & Otology 2008; 123:685-8. [PMID: 18925999 DOI: 10.1017/s0022215108003903] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Warfarin-induced skin necrosis is a rare but recognised complication of this drug. The condition predominantly affects the breasts, buttocks and thighs of obese, peri-menopausal women. We present the case of a patient with the condition in an unusual site, and we discuss the management challenges involved. CASE REPORT An 82-year-old man presented to the ENT department with a diagnosis of pinna haematoma. There was no history of trauma or infection. The patient was taking warfarin long-term for recurrent deep vein thrombosis. Two weeks prior to admission, the patient had had a loading course of warfarin following surgery. Multiple clinical teams were involved in treatment. The only abnormal laboratory investigation was a low protein S level; biopsy showed skin necrosis. CONCLUSION In this case, the unusual presentation created diagnostic confusion, and may have precipitated aggressive surgical debridement. However, a more conservative management strategy was used, which we would recommend in future.
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14
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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