Warfarin-Induced Skin Necrosis in a Patient with Heparin-Induced Thrombocytopenia: Two Diseases or One?

Abstract

A 64-year-old woman with colon carcinoma presented with subsegmental pulmonary emboli. Platelet count on presentation was 598 ×10⁹/l. The patient was anticoagulated with intravenous heparin. By hospital day 3, heparin was replaced with enoxaparin and warfarin. On hospital day 6, the patient developed a 20 × 15 cm area of necrotic skin on her left hip and a 1 × 3 cm area of necrosis on her right hip. By that time, her platelet count had fallen to 433 ×10⁹/l. Three days later (hospital day 9), anticoagulation was switched from the combination of enoxaparin and warfarin to argatroban. Her platelet count reached a nadir of 82 ×10⁹/l by the 12th hospital day. The areas of skin necrosis had never been sites of heparin injection. Heparin/platelet factor 4 antibody, sent on hospital day 9, returned positive and ¹⁴C-serotonin release assay was also positive. This case illustrates that processes underlying heparin-induced thrombocytopenia (HIT) may also underlie warfarin-induced skin necrosis. Skin necrosis may be the earliest manifestation of HIT and need not be accompanied by thrombocytopenia. This patient’s course illustrates that HIT should be considered in all patients presenting with skin necrosis while receiving anticoagulation with heparin or a combination of heparin and warfarin.

Heparin-based hydrogel scaffolding alters the transcriptomic profile and increases the chemoresistance of MDA-MB-231 triple-negative breast cancer cells

“…Additionally, heparin, in particular, is often administered as an anticoagulant to cancer patients receiving chemotherapy. 56 Heparin-induced thrombocytopenia in cancer patients has been previously documented. 57 The side-effects of heparin, in the context of changes in the transcriptomic profile, have not been well studied.…”

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

“…7 Warfarin necrosis has also been reported in patients receiving heparin. 8–10 Later occurrence up to 18 months may be associated with discontinuation and re-initiation of warfarin or displacement of albumin-bound warfarin by other drugs. 11 However, this patient had been on warfarin therapy for years and neither of these factors seemed to apply.…”

“…Several reports describe simultaneous FVL mutation and HIT and also the concomitant existence of WISN and HIT. 8–10,15 Some authors speculate that FVL mutations increase the rate at which thrombocytopenia and thrombosis develop in patients with HIT. 14 Warfarin treatment of HIT patients can lead to severe thrombotic complications, including limb gangrene.…”

Pulmonary Embolism: Some Issues of Epidemiology and Treatment in Cancer Patients

“…Дозировку варфарина следует подбирать, основываясь на ежедневном показателе свертываемости крови -международном нормализованном отношении (при правильном подборе дозы он должен колебаться в диапазоне 2-3). Однако следует иметь в виду, что применение варфарина у онкологических пациентов может сопровождаться некротическими изменениями кожных покровов [25], кровотечением и/или образованием гематомы, например, в экстрадуральном пространстве спинного мозга [26]. Следует также помнить: на фоне химиотерапии у онкологических пациентов возможно увеличение риска развития ТЭЛА при проведении ее профилактики варфарином [27].…”