warfarin and Livedo-Reticularis

Classic calciphylaxis associated with renal failure is a life-threatening disease. Warfarin-associated calciphylaxis without renal injury has been described, but whether it is a subset of classic calciphylaxis or a different entity remains unknown. We describe 1 case of warfarin-associated calciphylaxis, present data from 2 others from our institution, and review all cases of warfarin-associated calciphylaxis available in the literature. Our review indicates that warfarin-associated calciphylaxis is clinically and pathophysiologically distinct from classic calciphylaxis.. To review warfarin-associated calciphylaxis and determine its relationship to classic calciphylaxis.. We searched MEDLINE and Ovid without language or date restrictions for case reports of calciphylaxis from the inpatient setting using the terms "calciphylaxis and warfarin," "non-uremic calciphylaxis," and "nonuremic calciphylaxis." We defined nonuremic calciphylaxis as a histopathologic diagnosis of calciphylaxis without severe kidney disease (serum creatinine level >3 mg/dL; glomerular filtration rate <15 mL/min; acute kidney injury requiring dialysis; and renal transplantation).. Each patient had been exposed to warfarin before the onset of calciphylaxis.. Patient data were abstracted from published reports. Original patient medical records were requested and reviewed when possible.. We identified 18 patients with nonuremic calciphylaxis, 15 from the literature, and 3 from our institution. Patients were predominantly female (15 of 18 [83%]) with ages ranging from 19 to 86 years. Duration of warfarin therapy prior to calciphylaxis onset averaged 32 months. Lesions were usually located below the knees (in 12 of 18 [67%]). No cases reported elevated calcium-phosphate products (0 of 17 [0%]). Calcifications were most often noted in the tunica media (n = 8 [44%]) or in the vessel lumen and tunica intima (n = 7 [39%]). The most common treatments included substitution of heparin or low-molecular weight heparin for warfarin (n = 13 [72%]), intravenous sodium thiosulfate (n = 9 [50%]), and hyperbaric oxygen (n = 3 [17%]). The survival rate on hospital discharge was remarkably high, with 15 cases (83%) reporting full recovery and 3 cases ending in death.. Warfarin-associated calciphylaxis is distinct from classic calciphylaxis in pathogenesis, course, and, particularly, outcome. This finding should influence clinical management of the disease and informs targeted treatment of the disease.

Topics: Anticoagulants; Calciphylaxis; Female; Humans; Leg Ulcer; Livedo Reticularis; Purpura; Warfarin

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.

Topics: Anetoderma; Anticoagulants; Antiphospholipid Syndrome; Calciphylaxis; Hemostasis; Heparin; Humans; Livedo Reticularis; Necrosis; Platelet Aggregation Inhibitors; Purpura; Skin; Skin Diseases; Thrombophilia; Varicose Ulcer; Venous Thrombosis; Warfarin

Calcific uremic arteriolopathy (CUA) is a highly morbid condition usually found in ESRD patients that has rarely been reported after renal transplantation and renal function restoration. Furthermore, little is known about the optimal management of CUA in this setting. Herein, we report on the clinical case of AB, a 70-year-old woman who developed CUA after renal transplantation and renal function restoration. However, other risk factors for CUA such as diabetes and warfarin treatment, due to mechanical aortic valve implantation, were present. Thirty-eight months after renal transplantation she developed erythema and livedo reticularis in both legs and a gradually enlarging skin ulcer in the right leg. A skin biopsy of the ulcer showed features compatible with the CUA, such as sub-intimal calcification and luminal obstruction of the small dermal arterioles, tissue ischemia and signs of adipocytes degeneration. A multidisciplinary approach was adopted, including medical and non-medical treatments such as surgical debridement and vacuum-assisted closure therapy. Medical treatments included a five weeks course of once a week intravenous infusion of pamidronate and intravenous sodium thiosulfate (STS) at increasing doses. Four months after beginning the therapy with STS, a complete healing of the ulcer on the right leg and the disappearance of the livedo reticularis on the left leg was noted. In conclusion, although rare CUA may develop also in renal transplanted patients, a timely and combined therapeutic approach is essential for its resolutive treatment. Sodium thiosulfate therapy has proven to be effective and tolerated.

Topics: Aged; Anticoagulants; Bone Density Conservation Agents; Calciphylaxis; Chelating Agents; Combined Modality Therapy; Diabetes Mellitus; Female; Humans; Kidney Transplantation; Leg Ulcer; Livedo Reticularis; Pamidronate; Rare Diseases; Risk Factors; Thiosulfates; Warfarin

Topics: Adult; Antibodies, Anticardiolipin; Antibodies, Antiphospholipid; Anticoagulants; Antiphospholipid Syndrome; Diagnosis, Differential; Dyspnea; Echocardiography; Endocarditis, Non-Infective; Female; Heparin; Humans; Livedo Reticularis; Mitral Valve Insufficiency; Radiography, Thoracic; Symptom Assessment; Treatment Outcome; Warfarin

Topics: Adolescent; Female; Humans; Livedo Reticularis; Necrosis; Protein S Deficiency; Skin; Warfarin

Cholesterol crystal embolism (CCE) is a serious complication associated with invasive vascular procedures. The prognosis of the renal involvement type of CCE is very poor, and there is currently no established treatment, other than supportive therapy. We herein report four cases of CCE with severe atherosclerosis wherein the renal function progressively deteriorated after cardiac catheterization. In three of the four patients, low-dose corticosteroids (0.3 mg/kg/day) improved the renal function, whereas the fourth patient died from CCE of the digestive system. This report reviews the literature on CCE and discusses possible therapeutic options.

Topics: Acute Kidney Injury; Aged; Aortography; Cardiac Catheterization; Comorbidity; Coronary Angiography; Coronary Disease; Crystallization; Embolism, Cholesterol; Fatal Outcome; Humans; Intestinal Perforation; Intestines; Ischemia; Leg; Livedo Reticularis; Male; Middle Aged; Peripheral Vascular Diseases; Prednisolone; Recurrence; Toes; Warfarin

Topics: Anticoagulants; Female; Humans; Lipoprotein(a); Livedo Reticularis; Middle Aged; Ulcer; Warfarin; Young Adult

We report herein a case of a 28-year-old woman with persistent livedo racemosa and recurrent ulcerations on the lower extremities. The clinical presentation, together with histopathological findings of vascular occlusion without overt vasculitis in the dermis, led to the diagnosis of livedoid vasculopathy. The patient experienced recurrence of ulcerations and developed peripheral neuropathy affecting the distal extremities during the course of treatment with sarpogrelate hydrochloride. The skin lesions and neurological symptoms improved dramatically after adding low-dose warfarin potassium to the treatment regimen. This case suggests that administration of low-dose warfarin is an effective therapy of choice for patients with livedoid vasculopathy.

Topics: Adult; Anticoagulants; Female; Humans; Leg; Leg Ulcer; Livedo Reticularis; Mononeuropathies; Succinates; Vasculitis; Warfarin

A 50-year-old woman had a lifelong history of painful ulcerations as a result of livedoid vasculopathy. She was a heterozygous carrier of factor V Leiden and prothrombin gene mutations and was receiving hormone replacement therapy. The ulcers healed after warfarin therapy, which has been reported to be effective in only one previous patient with this condition.

Topics: Anticoagulants; Factor V; Female; Heterozygote; Humans; Leg Ulcer; Livedo Reticularis; Middle Aged; Mutation; Prothrombin; Skin Diseases, Vascular; Thrombophilia; Warfarin