Late-onset warfarin necrosis.
A 43-year-old woman developed tenderness and induration of her thighs and lower abdomen, 56 days after commencing warfarin for aortic and mitral valve replacements. Investigations showed elevated inflammatory markers, mild renal impairment, normal echocardiogram and low protein C and S levels consistent with warfarin therapy. Three weeks later, purpuric areas evolved into large tender haemoserous bullae, which broke down to form ulcers. Histology confirmed the clinical impression of warfarin-induced skin necrosis with dermal and subcutaneous venular thrombi. Despite cessation of warfarin and commencement of heparin, the lesions progressed. When the patient became febrile, blood cultures grew Pseudomonas aeruginosa, which was treated with intravenous imipenem and vancomycin. Wound swabs grew methycillin-resistant Staphylococcus aureus and the antibiotics were changed. The patient developed septic shock and, despite intensive care management, her condition deteriorated and she died 9 weeks after the onset of the skin symptoms.
Department of Medicine (Dermatology), The University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.
Catherine E
CE
Scarff
Chris
C
Baker
Prue
P
Hill
Peter
P
Foley
D000328:Adult; D001021:Aortic Valve; D001707:Biopsy, Needle; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D017809:Fatal Outcome; D005260:Female; D006350:Heart Valve Prosthesis; D006801:Humans; D008943:Mitral Valve; D009336:Necrosis; D011182:Postoperative Care; D012214:Rheumatic Heart Disease / Q000175:diagnosis / Q000601:surgery; D012720:Severity of Illness Index; D012883:Skin Ulcer / Q000139:chemically induced* / Q000473:pathology* / Q000628:therapy; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects* / Q000627:therapeutic use
D014859:Warfarin