Heparin Skin Necrosis in Heparin-Induced Thrombocytopenia

Abstract

A 66-year-old woman presented with painful abdominal skin necrosis where she had been injecting subcutaneous enoxaparin 1 week following elective knee arthroplasty (Figure). Her complete blood cell count and basic metabolic panel yielded unremarkable findings. Enoxaparin was discontinued, and a direct thrombin inhibitor was started. Heparin platelet factor 4 IgG antibody was strongly positive (2.065 OD), as was the serotonin release assay—findings consistent with the diagnosis of heparin skin necrosis and heparin-induced thrombocytopenia.1Warkentin T.E. Roberts R.S. Hirsh J. Kelton J.G. Heparin-induced skin lesions and other unusual sequelae of the heparin-induced thrombocytopenia syndrome: a nested cohort study.CHEST. 2005; 127: 1857-1861Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Ultrasound imaging was negative for deep venous thrombosis. The patient was discharged on a regimen of therapeutic rivaroxaban and did well without need for surgical debridement. Heparin skin necrosis is a rare presentation of heparin-induced thrombocytopenia that can complicate either low-molecular-weight or unfractionated heparin therapy. Normal platelet counts are common and do not preclude the diagnosis. A 66-year-old woman presented with painful abdominal skin necrosis where she had been injecting subcutaneous enoxaparin 1 week following elective knee arthroplasty (Figure). Her complete blood cell count and basic metabolic panel yielded unremarkable findings. Enoxaparin was discontinued, and a direct thrombin inhibitor was started. Heparin platelet factor 4 IgG antibody was strongly positive (2.065 OD), as was the serotonin release assay—findings consistent with the diagnosis of heparin skin necrosis and heparin-induced thrombocytopenia.1Warkentin T.E. Roberts R.S. Hirsh J. Kelton J.G. Heparin-induced skin lesions and other unusual sequelae of the heparin-induced thrombocytopenia syndrome: a nested cohort study.CHEST. 2005; 127: 1857-1861Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Ultrasound imaging was negative for deep venous thrombosis. The patient was discharged on a regimen of therapeutic rivaroxaban and did well without need for surgical debridement. Heparin skin necrosis is a rare presentation of heparin-induced thrombocytopenia that can complicate either low-molecular-weight or unfractionated heparin therapy. Normal platelet counts are common and do not preclude the diagnosis.