RT Book, Section
A1 Sharma, Aditya M.
A1 Bartholomew, John R.
A2 Dean, Steven M.
A2 Satiani, Bhagwan
A2 Abraham, William T.
SR Print(0)
ID 1105291707
T1 HEPARIN-, LOW–MOLECULAR WEIGHT HEPARIN–, AND WARFARIN-INDUCED SKIN NECROSIS
T2 Color Atlas and Synopsis of Vascular Diseases
YR 2015
FD 2015
PB McGraw-Hill Medical
PP New York, NY
SN 9780071749541
LK accesssurgery.mhmedical.com/content.aspx?aid=1105291707
RD 2024/04/18
AB A  53-year-old  woman  was  treated  with  intravenous  unfractionated  heparin  (UFH)  for  an  acute  pulmonary  embolism.  She  was  started  on  10  mg  of  warfarin  on  her  fourth  day  of  heparin  therapy.  Her  baseline  platelet  count  was  normal,  but  decreased  to  86  ×  109/L  by  day  7  of  treatment.  Her  international  normalized  ratio  (INR)  was  3.2  at  that  time  and  heparin  was  discontinued.  A  platelet  factor  4  (PF  4)–heparin  immunoassay  was  found  to  be  positive,  consistent  with  a  diagnosis  of  heparin-induced  thrombocytopenia  (HIT).  Three  days  later  she  developed  a  violaceous  discoloration  of  both  breasts  that  progressed  to  full-thickness  skin  necrosis  and  warfarin-induced  skin  necrosis  was  diagnosed  (Figure  62-1).  Warfarin  was  discontinued  and  the  direct  thrombin  inhibitor  (lepirudin)  instituted  as  the  platelet  count  dropped  further  to  22  ×  109/L.  She  ultimately  required  extensive  surgical  debridement  of  both  the  breasts  and  reconstructive  surgery.  Warfarin  was  later  resumed  cautiously  at  1  mg/d  after  full  platelet  recovery  (overlapped  with  lepirudin)  until  the  INR  was  therapeutic  (>2)  for  two  consecutive  days.