| Abstract | A 53-year-old man with lung adenocarcinoma developed pulmonary embolism and bilateral popliteal venous thrombosis. Treated with intravenous unfractionated heparin and discharged home on warfarin, he returned a week later with extending thrombosis. Treatment with heparin followed by warfarin was reinitiated. Twenty-four hours following the re-administration of warfarin, the patient's INR increased to 14.5. The platelet count dropped by more than 50%, and he developed venous limb gangrene of the left leg and skin necrosis of the right leg. Heparin-induced thrombocytopenia was ruled out, and coagulation studies showed a severe depletion of protein C as well as increased thrombin generation. The patient was transfused with fresh frozen plasma, and vitamin K was given. Heparin was continued, and after 4 weeks, the patient improved markedly showing only minimal necrosis of the toes. Venous limb gangrene is a major complication associated with warfarin therapy. Its pathogenesis is explained by a transient hypercoagulable state produced by protein C depletion that leads to microvascular thrombi progressing to venous limb gangrene. The present case emphasizes the importance of careful anticoagulation with heparin followed by slow initiation of low-dose warfarin, in order to minimize thrombotic complications. |
| Authors | Liviu Klein, Angel Galvez, Oana Klein, Juan Chediak
(Affiliation: Department of Medicine, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA.)
|
| Journal | American journal of hematology
(Am J Hematol)
Vol. 76
Issue 2
Pg. 176-9
(Jun 2004)
ISSN: 0361-8609 United States |
| PMID | 15164386
(Publication Type: Case Reports, Journal Article)
|
| Copyright | Copyright 2004 Wiley-Liss, Inc. |
| Chemical References |
- Anticoagulants
- Warfarin
- Heparin
|
| Topics |
- Adenocarcinoma
(complications)
- Anticoagulants
(adverse effects)
- Fatal Outcome
- Gangrene
(chemically induced, pathology)
- Heparin
(adverse effects)
- Humans
- Male
- Middle Aged
- Popliteal Vein
- Pulmonary Disease, Chronic Obstructive
(complications)
- Pulmonary Embolism
(complications, drug therapy)
- Thrombosis
(complications, drug therapy)
- Warfarin
(adverse effects)
|
