When prophylaxis turns pathologic: a case of LMWH-induced necrosis with secondary cellulitis

Low-molecular-weight heparins (LMWHs) are widely used during pregnancy and postpartum to prevent thrombosis and are generally safe. Rarely, they can trigger delayed hypersensitivity reactions causing skin necrosis and infection. Recognizing this complication is important for timely care.

A 40-year-old woman developed painful necrotic patches at enoxaparin injection sites on her abdomen and arm one week after cesarean delivery. The lesions were red, tender, and associated with elevated inflammatory markers, while platelet counts were normal, excluding heparin-induced thrombocytopenia. She was diagnosed with LMWH-induced delayed hypersensitivity complicated by cellulitis. Enoxaparin was stopped, and she recovered with apixaban, intravenous antibiotics, wound care, and partial debridement.

These reactions usually appear 5-14 days after starting LMWH and can mimic infection or thrombosis. They reflect T-cell-mediated vascular injury and require clinical attention.

LMWH-induced skin necrosis is rare but serious. Early recognition and switching to alternative anticoagulation are essential for favorable outcomes.