Abstract
Skin necrosis and limb gangrene are occasional thrombotic manifestations of anticoagulation therapy. We report a man heterozygous for the Factor V Leiden (FVL) mutation, and with a history of recurrent deep venous thrombosis, who initially presented with a necrotic skin lesion of the right flank while on warfarin therapy with a therapeutic international normalized ratio. Warfarin was discontinued and he received intravenous heparin. Thereafter he developed thrombocytopenia and pedal erythema and was diagnosed with heparin-induced thrombocytopenia (HIT). Heparin was replaced with argatroban. He ultimately underwent bilateral below-knee amputations for the thrombotic complications of the HIT. The initial necrotic lesion healed with antibiotics and wound care. Pathologic examination of multiple biopsy specimens revealed two separate lesions. One was necrotic tissue infiltrated with methicillin resistant Staphylococcus aureus having features of ecthyma gangrenosum. The second showed thrombotic changes consistent with HIT. The case illustrates the differential diagnosis of skin necrosis and limb gangrene in patients on warfarin and heparin, and also the clinical complexities that can occur in a FVL heterozygote.
Highlights
A 59 year old male presented with a 30x12 cm discolored lesion of acute onset on his right flank (Figure 1)
His history included a twenty pack year smoking history and recurrent DVT of the lower extremities and subsequent arterial thrombosis of the left lower extremity requiring angiography and thrombolysis. He had been on warfarin for five years and his therapeutic international normalized ratio (INR) was 2.6
The initial impression was that this represented warfarin induced skin necrosis (WISN), but doubt was raised because the timing did not seem appropriate
Summary
A 59 year old male presented with a 30x12 cm discolored lesion of acute onset on his right flank (Figure 1). He days after presentation he underwent debrideand the clinical complexities that can had discontinued the warfarin in December ment of necrotic flank tissue and placement of occur in a FVL heterozygote.
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