Skin necrosis after warfarin therapy.

A rare but potentially lethal complication of coumarin and its congeners is skin necrosis. A case of skin necrosis due to warfarin is reported and the literature is reviewed. It is suggested that if necrosis develops, the coumarin therapy should be terminated, and the patient should immediately be heparinized. Heparin, which never causes necrosis, can be used freely if further anticoagulation therapy is required, and may well prevent necrosis due to the thrombotic process.     

Warfarin induced skin necrosis

BACKGROUND: Warfarin induced skin necrosis is a rare complication with a prevalence of 0.01-0.1 per cent. It was first described in 1943. METHODS: A literature review was undertaken using Medline; all relevant papers on this rare compli-cation of warfarin therapy were used. RESULTS: There are several adverse skin manifestations associated with the use of oral anticoagulants, ranging from ecchymoses and purpura, haemorrhagic necrosis, maculopapular vesicular urticarial eruptions to purple toes. This article concentrates mainly on warfarin induced skin necrosis. The syndrome typically occurs during the first few days of warfarin therapy, often in association with the administration of a large initial loading dose of the drug. Although the precise nature of the disease is still unknown, advances in knowledge about protein C, protein S and antithrombin III anticoagulant pathways have led to a better understanding of the mechanisms involved in pathogenesis. Differential diagnosis between warfarin induced skin necrosis and necrotizing fasciitis, venous gangrene and other causes of skin necrosis may be difficult; the disease may also be confused with other dermatological entities. CONCLUSION: Warfarin induced skin necrosis, while rare, is an important complication. All surgeons should be aware of its existence.     

Coumarin necrosis of the penis

Coumarin-induced necrosis of the skin and subcutaneous tissue is an uncommon but well recognized complication of anticoagulant therapy. Although any area of skin may be involved necrosis of the penis is rare. We report a case of penile necrosis associated with coumarin therapy and review the literature.     

Disseminated Intravascular Coagulation,Meningococcal Infection,and Ischemic Changes Affecting the Lower Extremities: A Case Study

A middle-aged woman presented from an outside hospital with a diagnosis of Neisseria meningitidis and meningococcemia. A nonpalpable purpuric skin rash evolved into multiple wounds, with gradual necrosis of bilateral lower and upper extremities. Throughout the course of hospitalization, the patient developed ventricular tachycardia, normocytic anemia, thrombocytosis, Clostridium difficile infection, depression, and transient right eye blindness. The finding of decreased CH50 in the complement cascade was considered as the potential cause of the meningococcemia. The subsequent ischemia and necrosis of extremities were attributed to the systemic effect and trauma ensuing from N. meningitidis.     

A Case of Warfarin Skin Necrosis Despite Enoxaparin Anticoagulation in a Patient with Protein S Deficiency

Warfarin-induced skin necrosis is a rare complication associated with the use of oral anticoagulants. Most patients develop this at the initiation of therapy, often while still receiving intravenous unfractionated heparin (UFH). Recently, low-molecular-weight heparins (LMWHs) have gained wider use, providing an option for outpatient treatment of deep-vein thrombosis. The treatment protocols are similar to UFH, including the early initiation of oral anticoagulation with warfarin. A Medline search failed to reveal any cases of warfarin-induced skin necrosis while using a LMWH. We present a patient with protein S deficiency who developed warfarin skin necrosis despite appropriate anticoagulation with enoxaparin, and review the chemical and clinical difference between UFH and LMWH.     

Heparin skin necrosis: delayed occurrence in a patient on hemodialysis

A case of skin necrosis in a patient receiving intravenous (IV) heparin during routine intermittent hemodialysis is reported. Multiple erythematous, tender lesions developed over the abdomen and thighs and rapidly became necrotic. Biopsies showed fibrin thrombi in the dermal venules and capillaries, but no cellular infiltrate. The patient was in her third month of regular hemodialysis. Skin necrosis associated with the use of heparin usually occurs within 2 weeks of beginning heparin therapy and has not been reported in patients receiving heparin with hemodialysis. Possible mechanisms, including acquired antithrombin III deficiency leading to heparin-induced skin necrosis, are discussed.     

Cumarinnekrose bei einer jungen Patientin

Coumarin-induced necrosis is a rare but severe complication of therapy with coumarin or its derivatives. The pathophysiology is still not well known. A case of a very young female patient who suffered from Marcumar-induced necrosis with loss of a forefoot is described. The differential diagnosis includes among others phlegmasia cerulea dolens.     

Postoperative thrombocytosis as a marker for complications after urologic surgery

Objective: To determine whether thrombocytosis after urologic surgery is a random phenomenon or if it is related to postoperative complications. MATERIAL AND METHODS: We evaluated the postoperative course of patients who had a normal platelet count before surgery and developed significant thrombocytosis (platelet count> 500 x 10(9)/l) after surgery during the years 1991-2003. The rate of postoperative complications was compared among patients who did and did not develop thrombocytosis for the three commonest surgical procedures associated with the condition (radical cystectomy, percutaneous nephrolithotripsy and nephrectomy). RESULTS: A total of 179 patients developed thrombocytosis (mean+/-SD platelet count 580+/-105 x 10(9)/l; range 501-1,390 x 10(9)/l) after a mean of 13.6 days (SD 14.7 days) following surgery. In 90% of these patients, postoperative complications were diagnosed. The most frequent complications were as follows: urosepsis, n = 49 (27%); hemorrhage, n = 37 (21%); and thromboembolism, n = 15 (8.4%). These complications were diagnosed by means of clinical examination in 114 cases (64%), CT in 31 (17%), Doppler ultrasound in seven (4%) and other diagnostic modalities in nine. In 18 patients (10%), no apparent complication was diagnosed. The rate of postoperative complications was significantly higher among patients who developed thrombocytosis after surgery compared to those who did not (p < 0.00001). In 63 patients (35%), the finding of thrombocytosis preceded the diagnosis of the complication (by a median period of 5 days). In these patients, thrombocytosis was essentially an early marker for the impending complication. CONCLUSIONS: Postoperative thrombocytosis is not a random phenomenon. It is a serious sign that should not be ignored. Septic and thromboembolic complications should be actively sought by means of thorough clinical evaluation. CT of the abdomen should be considered in appropriate clinical settings. The timing of thrombocytosis and the pathologic spectrum of diseases demonstrated by patients with it justify classifying it as a marker of the subacute phase.     

Skin necrosis and oral anticoagulant therapy: a review of the literature

Summary In spite of the wide use of oral anticoagulant therapy, skin necrosis remains an infrequent complication. A thorough search of the earlier scientific literature in English revealed sporadic cases that cannot supply enough data about the nature of this rare phenomenon. More current articles have examined this complication with recently developed and more sophisticated hematologic tests. A summary and analysis of all reported cases (a total of 105) were undertaken, in an attempt to find a common denominator that would identify the possible cause(s) of the condition, thereby allowing for improved treatment. An imbalance between clotting factors, due to lack of protein C or factor VII, seems to be the most reasonable explanation for the phenomenon, although data to validate this theory are lacking.Dr. Sagi is a former Jacques Maliniac Fellow in the Microsurgery Laboratory     

Coumarin necrosis--a review of the literature

Skin and soft tissue necrosis is a rare complication of anticoagulation therapy. Two patients who exhibited the spectrum of this disorder are described. The clinical features, etiology, pathophysiology, and treatment of coumarin skin necrosis are outlined, and the English-language literature is reviewed.     

Lower limb compartment syndrome following lumbar discectomy in the knee-chest position

We report on two cases of compartment syndrome following lumbar discectomy in the knee-chest position. This complication has only been described once since 1953. Seven cases of compartment syndrome following other surgical procedures were found in the literature. Any increases in tissue pressure of a muscle compartment exceeding 35–40 mmHg over a longer period of time can result in this complication for example, too tight cast, space-occupying intrafascial bleeding, or postischemic swelling. The diagnosis is purely clinical and is based on the typical combination of extremely painful edema with rapid onset of sensory loss and subsequent motor deficits. The muscle necrosis leads to myoglobinaemia and myoglobinuria, recognizable by brown urine. The therapy consists of urgent fasciotomy of swollen compartements without skin suture. The prognosis is highly dependent on the time of the surgical decompression: within 6 hours serious deficits are avoidable; after 24 hours irreversible necrosis of muscle occurs. It seems that the possibility of a compartment syndrome is a specific, but a rare risk of a prolonged knee-chest position.     

Two surgical case reports showing atypical heparin-induced thrombocytopenia]

Heparin-induced thrombocytopenia (HIT) represents a serious side effect caused by an atypical immune response to platelet factor 4 leading to platelet activation and thrombin formation. These patients are at high risk of thromboembolism, with a rapid drop in platelet count between days 5 and 14 after the initiation of heparin treatment. In single cases, especially after major surgery, platelet count reduction might be absent or hidden by preceding thrombocytosis. Different clinical manifestations of HIT include unspecific skin reactions with potential necrosis at the site of heparin injection, mostly after the application of unfractionated heparin but also with low molecular weight heparin. In heparin-induced skin necrosis, administration of unfractionated or low molecular weight heparin is contraindicated and heparin therapy should be stopped immediately. Instead, an alternative anticoagulant in the form of a direct thrombin inhibitor such as argatroban, and respectively lepirudin, or danaparoid sodium must be administered. Due to frequent misinterpretations of heparin-induced unspecific skin reactions, especially in the absence of thrombocytopenia, we present two case reports which should increase the awareness of HIT's various clinical pictures.     

Heparininduzierte Thrombozytopenie

Heparin-induced thrombocytopenia (HIT) represents a serious side effect caused by an atypical immune response to platelet factor 4 leading to platelet activation and thrombin formation. These patients are at high risk of thromboembolism, with a rapid drop in platelet count between days 5 and 14 after the initiation of heparin treatment. In single cases, especially after major surgery, platelet count reduction might be absent or hidden by preceding thrombocytosis. Different clinical manifestations of HIT include unspecific skin reactions with potential necrosis at the site of heparin injection, mostly after the application of unfractionated heparin but also with low molecular weight heparin. In heparin-induced skin necrosis, administration of unfractionated or low molecular weight heparin is contraindicated and heparin therapy should be stopped immediately. Instead, an alternative anticoagulant in the form of a direct thrombin inhibitor such as argatroban, and respectively lepirudin, or danaparoid sodium must be administered. Due to frequent misinterpretations of heparin-induced unspecific skin reactions, especially in the absence of thrombocytopenia, we present two case reports which should increase the awareness of HIT’s various clinical pictures.     

Gastric necrosis complicating lately a Nissen fundoplication

Background Gastric necrosis after Nissen fundoplication is a rare and life-threatening complication described in paediatric surgery and in some experimental models. Prompt diagnosis and appropriate therapy of acute gastric dilatation is mandatory to avoid potentially fatal gastric necrosis. Case report This case report is the first one to describe a gastric necrosis in an adult as a late and very severe complication after Nissen fundoplication. Gastric dilatation and subsequent necrosis occurred 14 years after Nissen fundoplication because of small bowel obstruction based on adhesions. Conclusion Early diagnosis and treatment of gastric dilatation after Nissen fundoplication are essential to prevent from severe secondary complications but can be difficult to establish because of atypical symptoms.     

Coumadin-induced skin necrosis of the breasts: case report

A case report of coumadin-induced skin necrosis (CISN) is presented, followed by a topic review of CISN, which reviews presentation, pathophysiology, differential diagnosis, prevention, and management of this disorder. The prevalence of CISN is low (0.01%-0.1% of patients receiving coumadin). However, of those affected, over 50% required some form of surgical debridement or reconstruction. Although skin necrosis secondary to coumadin therapy is rare, it is essential for plastic surgeons to be aware of this clinical entity in order to make the correct diagnosis and provide appropriate treatment.     

Coumarin-induced skin necrosis

Coumarin skin necrosis is a rare and usually unpredictable complication of coumarin therapy, occasionally leading to death. Onset is usually between the third and sixth day of coumarin therapy. The patient most commonly complains of pain in a region of abundant subcutaneous fat, with progression to erythema, petechiae, and gangrenous necrosis. Thrombosis of the dermal and the subcutaneous veins is demonstrated pathologically. We describe a case and review the pathogenesis, treatment, and prevention of this lesion.     

He-Ne激光联合bFGF治疗减少腋臭术后并发症的疗效观察

目的：减少腋臭手术的并发症,促进切口的愈合。方法：60例腋臭,手术采用小切口皮瓣法,术后右侧腋窝采用氦氖激光照射6次,并在每次照射后用碱性成纤维细胞生长因纱布湿敷,左侧腋窝不采用任何治疗,两侧腋窝术后9天拆线。结果：患者右侧60侧腋窝皮瓣,58例痊愈,1例切口裂开,1例血肿。左侧60侧腋窝皮瓣,51例皮瓣痊愈,1例血肿,2例皮瓣坏死,3例切口裂开,6例皮瓣挛缩（其中包括2例皮瓣坏死,1切口裂开）,右侧腋窝并发症明显少于左侧（P〈0．05）,右侧腋窝皮瓣挛缩明显少于左侧（P〈0．05）。结论：小切口皮瓣法治疗腋臭,术后采用氦氖激光照射联合碱性成纤维细胞生长因子治疗促进切口愈合,减少并发症,减少腋窝皮瓣挛缩     

Extensive colonic necrosis complicating acute pancreatitis

Segmental ischemic gangrene of the colon is a rare complication of acute pancreatitis. Three patients with long-segment colonic necrosis complicating acute pancreatitis are reported. At operation all three patients had extensive retromesocolic necrolysis associated with colonic arterial thrombosis. Colonic resection and intestinal exteriorization with peripancreatic drainage were performed, with survival of two patients. Although diagnosis of colonic ischemia in the presence of acute pancreatitis is difficult, operative therapy affords reasonable cure when this severe problem is recognized.     

Unusual complication of radial artery cannulation

Currently, radial artery cannulation is the preferred method for continuous hemodynamic monitoring in critically ill patients. Reported complications of radial artery cannulation include infection, digital gangrene, thrombosis, pseudoaneurysm, skin necrosis and median nerve palsy. Radial artery catheter fracture is a very rare complication. A review of the English language literature revealed only one reported case.We present an additional case of spontaneous radial artery catheter fracture.     

The surgical management of superficial infections caused by atypical mycobacteria

We have recently treated four patients with atypical mycobacterial skin infections. Two patients were infected with Mycobacterium smegmatis after self-injection with a veterinary-grade anabolic steroid. To our knowledge, this complication has not been previously described. The other patients had steroid-dependent asthma and lower extremity infections involving M. kansasii and M. chelonei after minor household trauma developed. Atypical mycobacterial skin infections may be seen as chronic ulcerations with violaceous edges, rolled margins, and significant subcutaneous necrosis. An indolent course and the clinical appearance may aid in diagnosis. In our experience, limited incision and drainage or dressing changes fail to eradicate these infections, even when accompanied by appropriate antibiotic therapy. Successful treatment requires aggressive debridement of all infected subcutaneous tissues and skin. Split-thickness skin grafting was successfully used to cover large wounds. Grafting did not appear to foster recurrent infection.