Abstract

SAAD, EJ; RUSSO, V; KURPIS, M  and  TABARES, AH. Skin necrosis, thrombocytopenia and recurrent thrombosis in heart transplant patient. Rev. argent. dermatol. [online]. 2016, vol.97, n.1, pp.13-24. ISSN 1851-300X.

Cutaneous necrosis is a rare complication related to the treatment with vitamin-K antagonists. While its pathogenesis is not completely understood, it is presumed that it may represent an imbalance between procoagulants and anticoagulants factors that occur at the beginning of treatment with warfarin. Heparin-induced thrombocytopenia and warfarin-induced skin necrosis may coexist, leading to a prothrombotic state with subsequent skin necrosis and venous gangrene of the limbs. CASE REPORT A 66 year-old male, status post cardiac transplantation secondary to idiopathic dilated cardiomyopathy, presented with progressive renal insufficiency. The patient had received warfarin for the past 5 years for idiopathic left leg deep vein thrombosis. His treating physicians considered that the patient did not have an indication for extended anticoagulation, warfarin was discontinued and he was begun on hemodialysis 3 times a week. One month after warfarin suspension, the patient presented with massive right leg DVT and bilateral pulmonary embolism. Platelet count was 74000 /uL. He was started on unfractionated heparin (UFH) and warfarin, and platelet count dropped to 43000 /uL 3 days after beginning of treatment, and returned to baseline levels after heparin interruption. Approximately 27 days after hospital discharge, the patient was readmitted for extensive contralateral DVT and thoracic hematomas. On admission, the INR was 4.4 and platelet count 35000 /uL. UFH was started but had to be discontinued after 48 hs due to progressive thrombocytopenia. The patient developed a necrotic plaque with hemorrhagic bullae and erythematous halo on right pectoral area. Warfarin-induced skin necrosis was suspected and skin biopsy was performed that showed dermal capillary thrombosis and epidermic necrosis. Blood and fluid cultures from bullae were negative. Due to renal failure, it was planned to start the patient on low dose fondaparinux, and he suddenly died during hemodialysis. DISCUSSION Skin necrosis is a multifactorial condition with a broad differential diagnosis. The current case represented a great diagnostic and therapeutic challenge. Thrombocytopenia and recurrent thrombotic events associated with UNF treatment suggest HIT. Therapy with warfarin under these circumstances may exacerbate the prothrombotic state and predispose to capillary thrombosis with cutaneous and mammary gland fat necrosis.

Keywords : Warfarin; Thrombotic microangiopathy; Skin; Necrosis; Thrombocytopenia.