Warfarin-Induced Penile Necrosis in a Patient with Heparin-Induced Thrombocytopenia

Abstract

A 56-yr-old man with lung adenocarcinoma presented with subsegmental pulmonary thrombosis. Platelet count on presentation was 531×109/L. The patient was anticoagulated with subcutaneous low molecular weight heparin (LMWH). Next day, oral anticoagulation was initiated with 5 mg of warfarin once daily with LMWH and LMWH was discontinued at third hospital day. On the third day of oral anticoagulation therapy, he complained of left leg swelling and prolonged painful penile erection of 24 hr-duration. His platelet count reached a nadir 164×109/L at that time, and the patient had a deficiency of protein C and S, with an activity level of 16% and 20% of normal value. Warfarin was stopped and he underwent penile aspiration. The next day, left leg edema and penile erection was disappeared, but penile and glans penis necrosis was started. This case illustrates that processes underlying heparin-induced thrombocytopenia (HIT) may also underlie warfarin-induced skin necrosis.

A literature review of antithrombotic and anticoagulating agents on sexual function

“…Eight patients suffered from priapism related to usage of ATAs; acenocoumarol had been used in one case, and coumadin had been used in seven other cases (Abu Sham'a, Kufri, & Yassin, ; Chang, Ha, Chi, Kown, & Lee, ; Daryanani & Wilde, ; Mahapatra, Bhattacharya, Mishra, Kumar, & Saxena, ; Nagathan, Pahwa, Kumar, & Goel, ; Salerno, Charrette, & Morales, ; Touloupidis, Zoumpos, Kalaitzis, Vogiatzaki, & Chloropoulou, ; Zimbelman et al., ) (Table ) (LOE: 4). Their age was between 16 and 65 years, median age being 34.5 years.…”

“…Priapism mostly occurred 3 to 6 days following coumadin use, and the prothrombin time‐international ratio (PT‐INR) ranged from 2.2 to 9.8 with half of the ratios being at least 3.50. A coagulation profile was examined in six cases (Abu Sham'a et al., ; Chang et al., ; Daryanani & Wilde, ; Mahapatra et al., ; Touloupidis et al., ; Zimbelman et al., ), and coagulopathy was identified in four of the examined patients, including protein C deficiency in four cases (Abu Sham'a et al., ; Daryanani & Wilde, ; Mahapatra et al., ; Zimbelman et al., ), and protein S deficiency (Daryanani & Wilde, ) and activated protein C resistance (Daryanani & Wilde, ) and factor V Leiden mutation (Zimbelman et al., ) in one case respectively. There was no relationship between the time of onset, PT‐INR and coagulopathy.…”

“…Priapism with penile engorgement occurred in six cases, and penile gangrene (Nagathan et al., ) or skin necrosis (Chang et al., ) occurred in one case. In cases of priapism with penile engorgement, patients rapidly recovered after cavernous blood aspiration, irrigation, shunting or debridement.…”

“…In cases of priapism with penile engorgement, patients rapidly recovered after cavernous blood aspiration, irrigation, shunting or debridement. In the two cases of penile gangrene or skin necrosis (Chang et al., ; Nagathan et al., ), partial or total penectomy was subsequently performed. Unfortunately, one of the patients later died due to lung metastasis complications (Chang et al., ).…”

Anticoagulant-induced priapism progressing to penile gangrene: a devastating complication!

“…Penile gangrene has been noted only with the use of subcutaneous low-molecular-weight heparin (LMWH, Enoxaparin sodium, Clexane, Sanofi, Surrey) when used at the dose of 50 mg twice daily 13. Although priapsim has been noted with the use of intravenous and intracavernosal unfractionated heparin, penile gangrene has not been noted with the use of unfractionated heparin in the literature 1–11.…”