Warfarin-induced skin necrosis associated with acquired protein C deficiency

A 36-year-old woman developed skin necrosis of the inner thighs following the re-introduction of warfarin after a laparoscopic cholecystectomy. She had a history of liver disease and cardiomyopathy and was on warfarin for 10 years. Warfarin-induced skin necrosis secondary to protein C deficiency was diagnosed. Although warfarin was ceased immediately, the prothrombin time measurements remained prolonged and warfarin levels remained therapeutic. Our patient, who had attached great significance to warfarin therapy, had continued the ingestion of warfarin despite our advice. She required three surgical debridements. Protein C levels, as measured 1 year later, were within normal limits, confirming the transient nature of the acquired deficiency during the acute event. This is the second reported case of warfarin necrosis associated with acquired protein C deficiency.