Kamada Momoka, Kenzaka Tsuneaki
Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba 669-3395, Japan.
Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe 652-0032, Japan.
World J Clin Cases. 2019 Dec 26;7(24):4285-4291. doi: 10.12998/wjcc.v7.i24.4285.
Heparin is commonly recommended for warfarin-induced skin necrosis; however, there is currently no established therapy for this disease. We present a serious case of warfarin-induced skin necrosis that was successfully treated with oral rivaroxaban, a factor Xa inhibitor.
A 48-year-old woman was admitted to the hospital for cellulitis of the right lower extremity. After antibiotic treatment, she developed pain and swelling of the left lower extremity, and deep vein thrombosis of both lower extremities was diagnosed. She was treated with a continuous heparin injection; subsequently, oral warfarin was concomitantly administered. Heparin was terminated after the therapeutic range was reached. On the following day, the patient had swelling and pain in the left lower extremity. In addition to decrease in protein S activity due to systemic lupus erythematosus, warfarin also reduced protein C activity, resulting in further hypercoagulation and skin necrosis. Warfarin was discontinued, and continuous heparin injection was resumed. Although the patient had to undergo amputation of the distal end of her left foot, continuous heparin injection was switched to oral rivaroxaban, and she was eventually discharged from the hospital in remission.
Administration of direct oral anticoagulants instead of warfarin is important in patients with decreased protein S and C activity.
肝素通常被推荐用于华法林诱导的皮肤坏死；然而，目前尚无针对该疾病的确立疗法。我们报告了1例严重的华法林诱导的皮肤坏死病例，该病例成功地接受了口服利伐沙班（一种Xa因子抑制剂）治疗。
一名48岁女性因右下肢蜂窝织炎入院。抗生素治疗后，她出现左下肢疼痛和肿胀，诊断为双下肢深静脉血栓形成。她接受了持续肝素注射治疗；随后，同时给予口服华法林。达到治疗范围后停用肝素。次日，患者左下肢出现肿胀和疼痛。除了系统性红斑狼疮导致蛋白S活性降低外，华法林还降低了蛋白C活性，导致进一步的高凝状态和皮肤坏死。停用华法林，恢复持续肝素注射。尽管患者不得不接受左足远端截肢，但持续肝素注射改为口服利伐沙班，最终患者缓解出院。
对于蛋白S和C活性降低的患者，使用直接口服抗凝剂而非华法林很重要。
