Advertisement

Journal of Thrombosis and Thrombolysis

, Volume 49, Issue 1, pp 149–152 | Cite as

Warfarin induced leukocytoclastic vasculitis: an extraordinary side effect

  • Dina ElantablyEmail author
  • Ahmed Mourad
  • Ahmed Elantably
  • Mohamed Effat
Article
  • 110 Downloads

Abstract

Warfarin is one of the most commonly used anticoagulants in the management of thromboembolic events. Herein we report a rare case of warfarin induced leukocytoclastic vasculitis in a patient with history of rheumatic heart disease and a mechanical mitral valve prosthesis who presented with heart failure and palpable purpura. Upon clinical suspicion of cutaneous small vessel vasculitis, a comprehensive laboratory panel was performed. Warfarin induced vasculitis was suspected when withdrawal of warfarin, due to rising INR, led to improvement of the skin lesions. The diagnosis was finally confirmed when re-instatement of warfarin reproduced the skin lesions and a skin biopsy showed evidence for leukocytoclastic vasculitis with eosinophilic infiltration. A third of cases of leukocytoclastic vasculitis are due to drug hypersensitivity which being a diagnosis of exclusion with varying manifestations, requires a high index of clinical suspicion. Since drug induced leukocytoclastic vasculitis may affect multiple organ systems and even cause mortality, clinicians must be aware of this rare adverse event, promptly discontinue the drug, and commence anti-inflammatory or immunosuppressive treatment when necessary.

Keywords

Warfarin Leukocytoclastic vasculitis Drug induced hypersensitivity anticoagulants 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

References

  1. 1.
    Nishimura RA, Otto CM, Bonow RO et al (2014) 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129:e521–e643.  https://doi.org/10.1161/CIR.0000000000000031 CrossRefPubMedGoogle Scholar
  2. 2.
    Pirmohamed M (2006) Warfarin: almost 60 years old and still causing problems. Br J Clin Pharmacol 62:509–511.  https://doi.org/10.1111/j.1365-2125.2006.02806.x CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Grau RG (2015) Drug-induced vasculitis: new insights and a changing lineup of suspects. Curr Rheumatol Rep 17:1.  https://doi.org/10.1007/s11926-015-0545-9 CrossRefGoogle Scholar
  4. 4.
    Hsu C-Y, Chen W-S, Sung S-H (2012) Warfarin-induced leukocytoclastic vasculitis: a case report and review of literature. Intern Med Tokyo Jpn 51:601–606CrossRefGoogle Scholar
  5. 5.
    Yaghoubian B, Ngo B, Mak M et al (2005) Warfarin-induced leukocytoclastic vasculitis. Cutis 75:329–338PubMedGoogle Scholar
  6. 6.
    Tanay A, Yust I, Brenner S et al (1982) Dermal vasculitis due to coumadin hypersensitivity. Dermatologica 165:178–185CrossRefGoogle Scholar
  7. 7.
    Jumean K, Arqoub AA, Hawatmeh A et al (2016) Warfarin-induced leukocytoclastic vasculitis and proteinuria. J Fam Med Prim Care 5:160–162.  https://doi.org/10.4103/2249-4863.184643 CrossRefGoogle Scholar
  8. 8.
    Jennette JC, Falk RJ, Bacon PA et al (2013) 2012 Revised international Chapel Hill consensus conference nomenclature of vasculitides. Arthritis Rheum 65:1–11.  https://doi.org/10.1002/art.37715 CrossRefPubMedGoogle Scholar
  9. 9.
    Howitt AJ, Williams AJ, Skinner C (1982) Warfarin-induced vasculitis: a dose-related phenomenon in susceptible individuals? Postgrad Med J 58:233–234CrossRefGoogle Scholar
  10. 10.
    Di Minno A, Frigerio B, Spadarella G et al (2017) Old and new oral anticoagulants: Food, herbal medicines and drug interactions. Blood Rev 31:193–203.  https://doi.org/10.1016/j.blre.2017.02.001 CrossRefPubMedGoogle Scholar
  11. 11.
    Reaves AB, Clarke CJ, Tillman EM (2013) Supratherapeutic international normalized ratio due to reduced vitamin K intake secondary to prolonged vomiting in a patient on warfarin. Ann Pharmacother 47:e28.  https://doi.org/10.1345/aph.1R688 CrossRefPubMedGoogle Scholar
  12. 12.
    Radić M, Martinović Kaliterna D, Radić J (2012) Drug-induced vasculitis: a clinical and pathological review. Neth J Med 70:12–17PubMedGoogle Scholar
  13. 13.
    Gota CE, Calabrese LH (2013) Diagnosis and treatment of cutaneous leukocytoclastic vasculitis. Int J Clin Rheumatol 8:49–60.  https://doi.org/10.2217/ijr.12.79 CrossRefGoogle Scholar
  14. 14.
    Eikelboom JW, Connolly SJ, Brueckmann M et al (2013) Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med 369:1206–1214.  https://doi.org/10.1056/NEJMoa1300615 CrossRefPubMedGoogle Scholar
  15. 15.
    Anderson SL, Marrs JC (2018) Direct oral anticoagulant use in valvular heart disease. Clin Med Insights Ther 10:1179559X1775163. https://doi.org/10.1177/1179559X17751638 CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Faculty of MedicineCairo University Kasr AlainyCairoEgypt
  2. 2.Tufts UniversityBostonUSA
  3. 3.University of CincinnatiCincinnatiUSA

Personalised recommendations