Cutaneous dalteparin reactions associated with antibodies of heparin-induced thrombocytopenia

OBJECTIVE: To report widespread cutaneous lesions due to low-molecular-weight heparin therapy associated with heparin-induced thrombocytopenia (HIT), but without evidence of thrombocytopenia, and to review previously reported cases of skin reactions related to heparin therapy. CASE SUMMARY: A 59-year-old white man with a subtotally resected glioblastoma developed febrile neutropenia and pneumonia secondary to chemotherapy. The development of an upper extremity thrombosis, following insertion of a peripherally inserted central venous catheter, was treated with subcutaneous dalteparin. Cutaneous lesions developed distant from the site of injection. The diagnosis of HIT was confirmed despite stable platelet counts. Dalteparin therapy was discontinued immediately, and anticoagulation was maintained with warfarin. The skin lesions resolved without further complications. DISCUSSION: Numerous cases of heparin-induced cutaneous reactions have been reported. The majority of these describe a local reaction at the heparin injection site with or without associated thrombocytopenia. The case presented here is unique in that the observed skin reaction was distant to the injection site and occurred without thrombocytopenia, but with detectable heparin-dependent antibodies. CONCLUSIONS: Although a skin reaction is a rare complication of heparin therapy, it can be a clinical indicator of HIT despite normal platelet counts. Patients who develop skin lesions should have their heparin therapy discontinued and a diagnosis of HIT investigated.