title: Skin necrosis following prolonged administration of coumarin in a patient with inherited protein S deficiency.
abstract: Depression of the vitamin K-dependent modulators of coagulation during the initial phase of oral anticoagulant therapy may lead to a transient hypercoagulable state and skin necrosis. We report a case of skin necrosis associated with inherited protein S deficiency following prolonged coumarin therapy. As a result of a stasis ulceration causing a rise in c4b binding protein and concurrent treatment with topical sulfonamide, we hypothesize that a precipitous decrease in free protein S led to skin necrosis. Progression of the necrosis was halted with unactivated prothrombin complex concentrate. This case confirms the rare association between coumarin induced skin necrosis and protein S deficiency and emphasizes potential drug interactions.
authors.affiliation: Division of Hematology and Oncology, George Washington University Medical Center, Washington, DC 20037.
authors.forename: S L
authors.initials: SL
authors.lastname: Goldberg
authors.forename: C L
authors.initials: CL
authors.lastname: Orthner
authors.forename: B L
authors.initials: BL
authors.lastname: Yalisove
authors.forename: M L
authors.initials: ML
authors.lastname: Elgart
authors.forename: C M
authors.initials: CM
authors.lastname: Kessler
mesh_terms: D000328:Adult; D001798:Blood Proteins / Q000172:deficiency; D003374:Coumarins / Q000009:adverse effects*; D006023:Glycoproteins / Q000172:deficiency*; D006801:Humans; D008297:Male; D009336:Necrosis; D017293:Protein S; D012867:Skin / Q000187:drug effects* / Q000473:pathology; D013997:Time Factors
chemical_list: D001798:Blood Proteins; D003374:Coumarins; D006023:Glycoproteins; D017293:Protein S; C030123:coumarin