Deep Vein Thrombosis, Ecythyma Gangrenosum and Heparin-Induced Thrombocytopenia Occurring in a Man with a Heterozygous Factor V Leiden Mutation

Abstract

Skin necrosis and limb gangrene are occasional thrombotic manifestations of anticoagulation therapy. We report a man heterozygous for the Factor V Leiden (FVL) mutation, and with a history of recurrent deep venous thrombosis, who initially presented with a necrotic skin lesion of the right flank while on warfarin therapy with a therapeutic international normalized ratio. Warfarin was discontinued and he received intravenous heparin. Thereafter he developed thrombocytopenia and pedal erythema and was diagnosed with heparin-induced thrombocytopenia (HIT). Heparin was replaced with argatroban. He ultimately underwent bilateral below-knee amputations for the thrombotic complications of the HIT. The initial necrotic lesion healed with antibiotics and wound care. Pathologic examination of multiple biopsy specimens revealed two separate lesions. One was necrotic tissue infiltrated with methicillin resistant Staphylococcus aureus having features of ecthyma gangrenosum. The second showed thrombotic changes consistent with HIT. The case illustrates the differential diagnosis of skin necrosis and limb gangrene in patients on warfarin and heparin, and also the clinical complexities that can occur in a FVL heterozygote.

Ecthyma gangrenosum caused by Staphylococcus aureus in hematological malignancies: Case reports and literature review

“…Hematological malignancies Turnbull and Parry [5] (1981) 68 M Erythroleukemia MSSA + + + Oxacillin sodium: 4 wk − Turnbull and Parry [5] (1981) 59 M Waldenström's macroglobulinemia MSSA − + NA Oxacillin: duration unclear − Chang et al [6] (2012) 35 F ALL MRSA − + + Vancomycin: duration unclear − Dassan et al [7] [10] (2012) 8 mo F No comorbidities MRSA − + − Vancomycin: 21 d − Apstolova [11] (2012) 59 M FVL mutation MRSA − + − Antimicrobials and surgical debridement: type of regimen and duration unclear − Ungprasert et al [12] (2013) 40 M HIV MRSA − + − Vancomycin: 10 d; linezolid PO: 1 mo − Song et al [13] (2015) 15 mo F No comorbidities MSSA − + − Ceftriaxone → cefepime and clindamycin: 14 d − Ivanaviciene [14] (2016) 54 F Gastric adenocarcinoma MSSA − + + Acyclovir, meropenem, vancomycin → intravenous oxacillin: 2 wk − Santhaseelan and Muralidhar [15] (2017) 47 M Chronic alcoholic MRSA − + − Ceftriaxone → imipenem and amikacin with surgical debridement: duration unclear − Ulpiano Trillig et al [16] (2019) 27 M No comorbidities S. aureus, GAS − + − Antimicrobial therapy: 7 d − Ulpiano Trillig et al [16] (2019) 31 M HIV S. aureus, GAS − + − Antimicrobial therapy with surgical debridement: 14 d − Barry et al [17] (2021) 19 M CKD MRSA − + − Linezolid without surgical debridement: 4 wk − Shah et al [18] blood cultures returned positive. In the previous reports, 44% (74/167) of EG (any pathogen) was associated with positive blood culture results, while only 9% (4/44) of nonpseudomonal EG was associated with positive blood culture results.…”