Anticoagulation therapy for thromboembolism prevention: a case of warfarin-induced skin necrosis in the setting of protein C deficiency

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.

Rivaroxaban dose adjustment using thrombin generation in severe congenital protein C deficiency and warfarin-induced skin necrosis

“…To overcome WISN during anticoagulation, dabigatran and rivaroxaban have been used successfully in adults with PC deficiency, and rivaroxaban has been used in a child with protein S (PS) deficiency. [6][7][8] We report a case of severe PC deficiency in an adolescent treated with rivaroxaban after development of WISN. Physiologically, the thrombin-thrombomodulin complex activates PC; to preserve this natural anticoagulant mechanism, we preferred rivaroxaban to dabigatran in our patient.…”

Differential effects of direct factor IIa and factor Xa inhibitors in protein C‐deficient plasma detected using thrombin generation and viscoelastometry assays

“…However, these analyses included patients only with mild PC deficiency. Experience of DOACs or LMWH in severe PC deficiency is restricted to single case reports . The use of selective direct inhibitors of FIIa or FXa in other severe prothrombotic disorders such as antiphospholipid syndrome remains controversial because of incomplete efficacy in some studies …”

“…Experience of DOACs or LMWH in severe PC deficiency is restricted to single case reports. [20][21][22][23][24][25] The use of selective direct inhibitors of FIIa or FXa in other severe prothrombotic disorders such as antiphospholipid syndrome remains controversial because of incomplete efficacy in some studies. 15,26 The aim of this study was to evaluate the in-vitro effects of direct FIIa and FXa inhibitors, alongside the indirect dual FXa/FIIa inhibitor enoxaparin in PC-deficient plasma using modified thrombin generation and viscoelastometry assays that were sensitive to PC anticoagulant activity.…”

Warfarin-induced unilateral facial swelling and skin rash

“…Allergic cutaneous reactions in patients on warfarin are rare and reported at an incidence of less than 0.1% in the literature 1. Nevertheless, various types of warfarin-induced cutaneous reactions have been reported, including vesicular, maculopapular and urticarial lesions 1.…”

“…Nevertheless, various types of warfarin-induced cutaneous reactions have been reported, including vesicular, maculopapular and urticarial lesions 1. Warfarin-induced skin necrosis is a more serious dermatological condition that occurs in an estimated 1 in 10 000 patients exposed to warfarin.…”