Extensive Skin Necrosis Induced by Low-Molecular-Weight Heparin in a Patient With Systemic Lupus Erythematosus and Antiphospholipid Syndrome

Abstract

Low-molecular-weight heparin-induced skin necrosis can occur as a clinical feature of heparin-induced thrombocytopenia syndrome. Heparin-induced thrombocytopenia and antiphospholipid syndromes have some clinical features in common, including thrombocytopenia and thrombotic events. We describe a 46-year-old woman who developed extensive necrosis in the breast and other sites secondary to the use of enoxaparin after an elective hysterectomy. During the postoperative period, diagnoses of systemic lupus erythematosus and antiphospholipid syndrome were made because of some clinical and laboratory features (seizure, nephritis, bicytopenia, positive nuclear antibody, and positive antiphospholipid antibodies with a previous thrombotic event). The patient's clinical course improved only after corticosteroid therapy and the suspension of enoxaparin. Heparin-induced thrombocytopenia and antiphospholipid syndromes can have platelet factor 4 as a common denominator in their pathogenesis because platelet factor 4 tetramers can bind β2-glycoprotein molecules. This case suggests that use of low-molecular-weight heparins could be more risky in patients with an underlying immune disease and/or could trigger immune reactions that must be analyzed in larger studies.

Heparin-induced thrombocytopenia associated with low-molecular-weight heparin: clinical feature analysis of cases and pharmacovigilance assessment of the FAERS database

“…A total of 43 patients from 40 studies were included in this analysis after full-text screening, involving 39 case reports ( Plassat et al, 2002 ; Betrosian et al, 2003 ; Franke et al, 2003 ; Ng and Lee, 2003 ; Zamir et al, 2003 ; Dager and White, 2004 ; Patel and Knight, 2005 ; Doboszyńska et al, 2007 ; Rota et al, 2008 ; Famularo et al, 2009 ; Mumoli and Cei, 2010 ; Fesler et al, 2011 ; Illes et al, 2011 ; Iturbe et al, 2011 ; Yazbek et al, 2012 ; Klinkert et al, 2013 ; Leporini et al, 2013 ; Nazliel et al, 2014 ; Sinan et al, 2014 ; Brouns and Jie, 2015 ; Giuliani et al, 2015 ; Hantson et al, 2015 ; Koufakis et al, 2015 ; Larsen et al, 2015 ; Martinez and Burnett, 2015 ; Sartori et al, 2015 ; Wiegele et al, 2015 ; Pérez et al, 2016 ; Gan, 2017 ; Rivera et al, 2017 ; Le et al, 2019 ; Barcellona et al, 2020 ; Polák et al, 2020 ; Singh et al, 2020 ; Lovatt and Crowther, 2021 ; Tucker and Padarti, 2021 ; Byrne et al, 2022 ; Lázaro-García et al, 2022 ; Malinauskiene et al, 2022 ) and one case series ( Hartman et al, 2006 ) ( Figure 1 ). Patients’ information is summarized in Table 3 .…”