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Late-onset warfarin necrosis.

Catherine E Scarff1, Chris Baker, Prue Hill

  • 1Department of Medicine (Dermatology), The University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.

The Australasian Journal of Dermatology
|July 18, 2002
PubMed
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Warfarin-induced skin necrosis is a rare but severe complication. This case highlights the critical importance of recognizing this adverse reaction to warfarin therapy, especially in patients with protein C or S deficiency.

Area of Science:

  • Cardiology
  • Dermatology
  • Pharmacology

Background:

  • Warfarin is a commonly prescribed anticoagulant for patients with mechanical heart valves.
  • Warfarin therapy requires careful monitoring due to its narrow therapeutic index and potential for serious adverse effects.

Observation:

  • A 43-year-old woman developed painful skin lesions on her thighs and abdomen 56 days after starting warfarin for aortic and mitral valve replacements.
  • The lesions evolved from induration to bullae and ulcers, consistent with warfarin-induced skin necrosis.
  • The patient experienced superimposed infections with Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus, leading to septic shock.

Findings:

  • Histopathology confirmed warfarin-induced skin necrosis with dermal and subcutaneous venular thrombi.

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  • Low protein C and S levels were noted, consistent with warfarin's mechanism of action.
  • Despite anticoagulation with heparin and broad-spectrum antibiotics, the patient's condition rapidly deteriorated.

    • Implications:

    • Warfarin-induced skin necrosis is a thrombotic complication potentially exacerbated by underlying protein C or S deficiencies.
    • Early recognition and cessation of warfarin, along with appropriate anticoagulation and management of secondary infections, are crucial.
    • This case underscores the need for vigilance regarding rare but life-threatening warfarin adverse events.