Low Molecular Weight Heparin versus Coumadin-Induced Skin Necrosis in a Patient with Superficial Vein Thrombosis – A Case Report

Introduction: Coumadin and low molecular weight heparin (LMWH) induced skin necrosis are rare clinical conditions.
Case presentation: A 63-years-old female patient, known with hypertension and right-sided hemiparesis, had presented to the emergency departement with pain and erythema of her internal right thigh. Venous Doppler-echography showed internal safenous vein thrombosis, thus she was started on anticoagulant treatment with Dalteparin and Acenocoumarol. On the 5th day of treatment she developed plantar hematoma on her left leg, followed by the appearance of hematomas, on the lower third of her right calf and on coxofemoral regions. Therefore, we raised the suspicion of heparin or coumadin-induced cutaneous necrosis, we stopped the anticoagulation for 5 days and restarted it with the administration of Rivaroxaban, fresh frozen plasma, antibiotics and local, sterile, saline dressings. After four days the patient presented deep vein thrombosis on her left calf.
Results and Discussion: Coagulation abnormalities were suspected, but infirmed by normal values of specific laboratory tests, such as Protein C (472.2%), protein S (77.10%), lupus anticoagulant (LA1-screening 53, 5s, LA-confirmation 38,0s). Hemogram showed normal platelet values. To exclude a malignancy, abdominal CT scan was performed, which revealed a right adnexal inomogenic cystic lesion, CA-125 (6,5U/ml), requiring further gynecological investigations. For the treatment of skin lesions, the patient required necrectomy and skin graft application.
Conclusion: Particularly, considering that the patient was initially anticoagulated with LMWH and coumadins simultaneously, the etiology of her cutaneous lesions remains uncertain.