warfarin and Cellulitis

This reports an arm edema that was initially treated as cellulitis and later diagnosed to be subclavian thrombosis due to pacemaker wire irritation. We present an 87-year-old Caucasian man with 5 weeks duration of left arm swelling and pain that was treated with two courses of antibiotics. An axillary venous Doppler study was interpreted as normal with no evidence of venous thrombosis. However, a venogram showed evidence of thrombosis involving the left innominate, subclavian, and axillary veins with multiple collateral veins diverting the blood to the contralateral side and into the superior vena cava. Intravenous anticoagulation was initiated and subsequently the patient was maintained on warfarin (Coumadin). The thrombosis subsequently improved and the original pacemaker was maintained. Arm edema are commonly mistaken for cellulitis, causing a delay in a more definite diagnosis of subclavian thrombosis. In a setting of a patient with pacemaker, subclavian thrombosis should be considered even with a normal screening venous ultrasound test. The incidence, manifestation, venous Doppler, and venogram findings are reviewed and discussed. Upper arm edema and superior vena cava syndrome are the most common presentation of this subclavian thrombosis associated with pacemakers. Venous ultrasound tests may be normal and a venogram is usually required to establish a diagnosis.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arm; Axillary Vein; Brachiocephalic Veins; Cellulitis; Collateral Circulation; Diagnosis, Differential; Edema; Humans; Incidence; Injections, Intravenous; Male; Pacemaker, Artificial; Pain; Radiography; Subclavian Vein; Superior Vena Cava Syndrome; Thrombosis; Ultrasonography, Doppler; Vena Cava, Superior; Warfarin

Although atrial fibrillation (AF) occurs frequently in patients hospitalized with acute coronary syndrome (ACS), strategies for prevention of thromboembolic complications are poorly characterized.. We sought to examine exposure to warfarin and P2Y12 inhibitors and clinical outcomes among patients with AF and ACS.. Patients age >65 years hospitalized with a primary diagnosis of ACS and a secondary diagnosis of AF between 2007 and 2010 were identified in the Medicare 5% sample. Medication exposure was ascertained during a 90-day period following the index discharge using Medicare drug claims. Among patients who were alive and not readmitted during the ascertainment period, we examined the cumulative incidence of all-cause mortality and all-cause readmission by medication exposure at 1 year.. A total of 2509 Medicare beneficiaries met the inclusion criteria. Among the 1633 patients (65%) who were alive and not readmitted during the 90-day ascertainment period, 24.0% received warfarin, 38.9% received P2Y12 inhibitors, 10.2% received combination therapy, and 26.8% received neither therapy. Readmission rates were high in all groups at 1 year (warfarin, 47.5%; P2Y12 inhibitors, 46.6%; combination therapy, 38.0%; and neither therapy, 39.3%), and the overall 1-year mortality rate was 12.5%.. Among Medicare beneficiaries with AF and ACS, combination therapy with warfarin and P2Y12 inhibitor was uncommon during the 90-day ascertainment period, and more than one-quarter of patients had no claims for warfarin or P2Y12 inhibitors. Rates of all-cause readmission and mortality within 1 year of hospitalization for ACS were high.

Topics: Acute Coronary Syndrome; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Cardiovascular Diseases; Cellulitis; Comorbidity; Drug Therapy, Combination; Drug Utilization; Female; Gastrointestinal Diseases; Humans; Male; Medicare; Myocardial Revascularization; Patient Readmission; Pulmonary Disease, Chronic Obstructive; Purinergic P2Y Receptor Antagonists; Stents; Thromboembolism; United States; Warfarin

Calciphylaxis is a rare, usually fatal vasculopathic disorder characterized by cutaneous ischemia and necrosis due to calcification of arterioles. Although calciphylaxis is most frequently associated with end-stage renal disease (ESRD) and secondary hyperparathyroidism, it has been reported infrequently among patients on warfarin. No standard treatment has been established for atypical calciphylaxis; however, a potentially beneficial treatment is hyperbaric oxygen therapy (HBOT). A high degree of clinical suspicion, early diagnosis, and understanding the pathophysiology of this disease promotes the optimal management of this extremely morbid and often fatal condition.. We present a 63-year-old Polynesian woman with biopsy-proven calciphylaxis in the absence of ESRD or elevated serum calcium levels while taking warfarin. Therapeutic dose enoxaparin was substituted for warfarin and she received 40 sessions of HBOT during which lower extremity ulcers resolved.. Warfarin has been implicated when calciphylaxis presents in an atypical fashion. No guidelines exist for treatment of atypical calciphylaxis in the setting of concomitant warfarin therapy. Up to 80% of calciphylaxis patients die within 1 year of diagnosis. Our patient was changed to low-molecular-weight heparin and received HBOT.. We present what we believe is the first case of atypical calciphylaxis thought to be attributable to warfarin treated with a therapeutic substitution of anticoagulant and HBOT leading to resolution of cutaneous lesions.

Topics: Anti-Bacterial Agents; Anticoagulants; Calciphylaxis; Calcium-Binding Proteins; Cellulitis; Combined Modality Therapy; Debridement; Diabetes Mellitus, Type 2; Extracellular Matrix Proteins; Female; Humans; Hyperbaric Oxygenation; Leg Ulcer; Matrix Gla Protein; Middle Aged; Obesity, Morbid; Risk Factors; Thrombophilia; Warfarin

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Cellulitis; Drug Interactions; Emergency Treatment; Humans; Ibuprofen; Insect Bites and Stings; Warfarin

Topics: Anti-Bacterial Agents; Blindness; Cavernous Sinus Thrombosis; Cellulitis; Diabetic Coma; Diagnosis, Differential; Diplopia; Heparin; Humans; Orbit; Photophobia; Photosensitivity Disorders; Radiography; Sinus Thrombosis, Intracranial; Sinusitis; Vision, Ocular; Warfarin