warfarin and Skin-Ulcer

Calciphylaxis is a rare and severe disease that manifests with painful skin ulceration and necrosis. Herein, we report five patients of hemodialysis patients with skin biopsy-proven calciphylaxis at a single facility. One patient had undergone parathyroidectomy (PTx) due to severe secondary hyperparathyroidism, four had been treated with vitamin D receptor activators, and two were on warfarin therapy. All patients had hyperphosphatemia, and one had hypercalcemia. The intact parathyroid hormone level at diagnosis was 2 pg/ml in the patient after PTx, while three patients were within the target range. The average period after diagnosis of calciphylaxis was 2 months. Skin lesions were present on the thighs and lower legs in two patients, and on the dorsum of the foot in one patient. In skin biopsy, calcification was found in the arteriolar media in four patients, and calcium (Ca) was deposited in the dermal lesion in one patient. All patients received local cures, surgical debridement, antibiotics to control infectious diseases, and strict control of serum Ca and phosphate. Calcimimetics were used in all patients except one who had undergone PTx one month before, sodium thiosulfate was used in 4 patients, and low Ca dialysate was used in three patients. The average follow-up period was 7.4 months. Four patients were cured, and one died due to infection. We suggest that multidisciplinary management for infectious diseases, surgical debridement, strict control of mineral and bone markers from the early stage, and elimination of risk factors may improve the course of calciphylaxis, which is a life-threatening disease.

Topics: Adult; Aged; Calciphylaxis; Combined Modality Therapy; Female; Humans; Hypercalcemia; Hyperparathyroidism, Secondary; Hyperphosphatemia; Interdisciplinary Communication; Male; Middle Aged; Necrosis; Parathyroidectomy; Receptors, Calcitriol; Renal Dialysis; Skin Ulcer; Treatment Outcome; Warfarin

Other than the classic skin necrosis induced by oral anticoagulants (OAC) in patients with protein C and S deficiencies, other types of OAC induced-skin ulcers are little known. Herein, we describe an original case of recurrent pyoderma gangrenosum (PG)-like ulcers induced by OAC.. A 70-year-old female heart-transplant recipient presented deep, hyperalgesic and quickly-spreading necrotic ulceration of the right leg 6 weeks after starting oral anticoagulant therapy with fluindione. Histological analysis revealed dermal infiltrate containing polynuclear neutrophils, which accords with the histopathological diagnosis of leukocytoclastic vasculitis or PG. Infectious, autoimmune and thrombophilic causes were ruled out. Fluindione was withdrawn and the ulcer healed completely within a month. Six months later, right leg ulceration recurred two weeks after the patient resumed fluindione but healed within 1 month of discontinuation of the drug. An OAC from another chemical family (warfarin) was then introduced, with further recurrence of ulceration after 2 weeks of treatment.. The chronology of events and the negativity of aetiological explorations allowed a diagnosis to be made of OAC-induced skin ulcer, a rare complication of which the pathophysiology is unclear. This is the first case of PG-like ulcers induced by OAC.

Topics: Aged; Anticoagulants; Bed Rest; Carcinoma, Basal Cell; Diagnosis, Differential; Drug Eruptions; Drug Substitution; Facial Neoplasms; Female; Heart Transplantation; Humans; Hyperalgesia; Molecular Structure; Monoclonal Gammopathy of Undetermined Significance; Phenindione; Postoperative Complications; Pyoderma Gangrenosum; Recurrence; Skin Neoplasms; Skin Ulcer; Thrombophlebitis; Vasculitis, Leukocytoclastic, Cutaneous; Warfarin

Topics: Calciphylaxis; Heparin; Humans; Male; Middle Aged; Renal Insufficiency, Chronic; Skin Ulcer; Warfarin

Calciphylaxis is a rare life-threatening form of skin necrosis. Although traditionally observed in patients with end-stage renal disease and/or hyperparathyroidism, calciphylaxis has also been reported to occur in 'non-traditional' patients with normal renal and parathyroid function. We report a case of warfarin-induced calciphylaxis treated successfully with sodium thiosulphate and discuss the role of Vitamin K2 as a potential therapeutic option in the management of warfarin-induced calciphylaxis.

Topics: Anticoagulants; Antioxidants; Calciphylaxis; Drug Eruptions; Humans; Male; Middle Aged; Skin Ulcer; Thiosulfates; Warfarin

Calciphylaxis or calciphic uremic arteriolopathy (CUA) is a rare syndrome characterized by the deposition of calcium within the walls of small and medium size vessels in the dermis and in the subcutaneous tissue. The disease mainly affects patients with end-stage renal disease. We report here our experience with 4 cases of calciphylaxis in dialysis patients. The main predisposing factor observed in our 4 patients was warfarin use (2 patients, 50%), while local traumas and diabetes were respectively present in only one patient. None of our patients was obese. Lower legs were the most frequently involved site of CUA (3/4 patients, 75%). In our experience biopsy was crucial to achieve a correct diagnosis and did not cause aggravation of the ulcers. Therapeutic approach was multimodal: mainly hyperbaric oxygen therapy, cinacalcet and sodium thiosulphate. Although many recent case reports have shown exceptional results and healing with the use of sodium thiosulphate, we did not experience any change in the poor prognosis of our patients with the use of this drug, at a dosage of 5 g thrice weekly endovenously.

Topics: Aged; Aged, 80 and over; Anti-Bacterial Agents; Biopsy; Calciphylaxis; Cinacalcet; Combined Modality Therapy; Fatal Outcome; Female; Hemodialysis Solutions; Heparin; Humans; Hyperbaric Oxygenation; Kidney Failure, Chronic; Leg Ulcer; Male; Middle Aged; Naphthalenes; Prognosis; Renal Dialysis; Skin Ulcer; Thiosulfates; Warfarin

A 43-year-old woman developed tenderness and induration of her thighs and lower abdomen, 56 days after commencing warfarin for aortic and mitral valve replacements. Investigations showed elevated inflammatory markers, mild renal impairment, normal echocardiogram and low protein C and S levels consistent with warfarin therapy. Three weeks later, purpuric areas evolved into large tender haemoserous bullae, which broke down to form ulcers. Histology confirmed the clinical impression of warfarin-induced skin necrosis with dermal and subcutaneous venular thrombi. Despite cessation of warfarin and commencement of heparin, the lesions progressed. When the patient became febrile, blood cultures grew Pseudomonas aeruginosa, which was treated with intravenous imipenem and vancomycin. Wound swabs grew methycillin-resistant Staphylococcus aureus and the antibiotics were changed. The patient developed septic shock and, despite intensive care management, her condition deteriorated and she died 9 weeks after the onset of the skin symptoms.

Topics: Adult; Aortic Valve; Biopsy, Needle; Disease Progression; Dose-Response Relationship, Drug; Drug Administration Schedule; Fatal Outcome; Female; Heart Valve Prosthesis; Humans; Mitral Valve; Necrosis; Postoperative Care; Rheumatic Heart Disease; Severity of Illness Index; Skin Ulcer; Time Factors; Warfarin