warfarin and Spondylitis--Ankylosing

Vascular complications are frequent in long-term dialysis patients. The differential diagnosis is complex and includes immunological derangement (underlying disease, uremia), vasculopathic-atheroembolic diseases, calciphylaxis, infections, neoplasm, coagulation disorders, and adverse drug effects.. We report on a 50-year-old male patient with a long follow-up on renal replacement therapy (20 years), currently on daily hemodialysis. The patient's history of kidney transplantation was complicated by seven acute rejection episodes and by Kaposi sarcoma; comorbidity included HLA-B27 positive ankylosing spondylitis, diffuse vascular disease, recurrent atrial fibrillation, chronic hypotension, HCV positivity. Ten days after the start of warfarin for an atrial fibrillation episode, the patient developed digital necrotising ulcerations, rapidly evolving into partial symmetric digital gangrene at distal phalanxes. The timing and evolution of the lesions and the finding of protein S deficiency were the clues for diagnosing warfarin-induced skin necrosis (WISN); the drug was discontinued and therapy with low-molecular weight heparin, plasma and prostacyclin achieved slow resolution of lesions.. According to a combined MEDLINE and EMBASE search, this is the first report of WISN in a hemodialysis patient: underlining the clinical relevance of this uncommon problem, this case exemplifies the difficult differential diagnosis of acute vascular skin lesions in dialysis

Topics: Anticoagulants; Databases as Topic; Diagnosis, Differential; Dialysis; Fingers; Gangrene; HLA-B27 Antigen; Humans; Male; Middle Aged; Necrosis; Renal Replacement Therapy; Skin; Spondylitis, Ankylosing; Vascular Diseases; Warfarin

This case report illustrates an unusual complication of chronic warfarin administration.. The presurgical determination that the destructive process at L1-L2 was not infection or neoplasm involved the recognition that there was instability at this level resulting from chronic stress fractures.. Periosteal or osseous hemorrhagic masses (pseudotumors) have been well described in patients with hemophilia. To the authors' knowledge, this is the first reported case of this well-known phenomenon occurring in the axial skeleton as a consequence of warfarin administration.. Serial radiographic studies of the lumbar spine were available showing a progressive destructive lesion at L1-L2 and coinciding with the initiation of warfarin anticoagulation after aortic valve replacement.. The destructive mass was demonstrated surgically to represent a large partially solidified chronic hematoma.. Patients with stress fractures of the posterior arch and subsequent instability may be subject to development of such a spondyloarthropathy. Recognition of this unusual potential complication of warfarin therapy would prevent an incorrect diagnosis of tumor or infection. Early recognition of its occurrence could lead to early spinal stabilization.

Topics: Aged; Fractures, Stress; Hematoma; Humans; Lumbar Vertebrae; Male; Radiography; Spinal Diseases; Spondylitis, Ankylosing; Warfarin

Topics: Aged; Anticoagulants; Arthritis, Rheumatoid; Arthroplasty; Aspirin; Blood Coagulation; Blood Platelets; Dextrans; Follow-Up Studies; Heparin; Hip Joint; Humans; Joint Prosthesis; Osteoarthritis; Postoperative Complications; Spondylitis, Ankylosing; Vitamin K; Warfarin