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Consult Guys
In the Hot Seat:
What Is This Rash After LowMolecular-Weight Heparin?
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Copyright © 2016
The skin lesions are black, raised, not painful, no redness
at the base and located only on the hands.
Govind B, Gnass E, Merli G, Eraso L. Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation.
Hosp Pract (1995). 2016;44:103-7. [PMID: 26928382] doi:10.1080/21548331.2016.1159908
Case
• Labs:
• Hgb 12.4, Hct 38, WBC 8K
• Plts: 230K
• SCr 1, CrCl 70 cc/min,
• LFTS Normal
• PTT 30s, INR 1.1
Copyright © 2016
The Patient
 62-year-old, hypertension, hypothyroid
 DVT history 2 years ago, long haul flight
 Travel to New Mexico
 Hot tub
 LMWH prophylaxis prior to flight
 B cell lymphoma
Copyright © 2016
Heparin Induced Thrombocytopenia
Skin Lesions
• HIT
1.
2.
3.
Only 2 doses of
enoxaparin
Platelet count normal
Skin lesion not
necrotic
Reprinted from The Lancet www.thelancet.com, 380,
Schindewolf M, Heparin-Induced Skin Lesions, 1867-79,
Copyright 2012,with permission from Elsevier.
Schindewolf M, et al. Heparin-Induce Skin Lesions. Lancet 2012;380:1867-79.
Hypersensitivity Reaction
UFH & LMWHs
1. Areas at injection
site are red and
warm
2. Hive like skin
reaction
Reprinted from The Lancet www.thelancet.com, 380, Schindewolf M, Heparin-Induced Skin Lesions, 1867-79,
Copyright 2012,with permission from Elsevier.
Schindewolf M, et al. Heparin-Induce Skin Lesions. Lancet 2012;380:1867-79.
Injection Site Hematomas
B-Cell Lymphoma Skin Lesions
Reprinted from The Journal of the American College of Dermatology, www.jaad.org, 69,
Servitje O, Primary cutaneous marginal zone B-cell lymphoma: Response to treatment
and disease-free survival in a series of 137 patients, 357-365, Copyright 2013,with permission from Elsevier.
Serviteje O, et al. Primary cutaneous marginal zone B-cell lymphoma: Response to treatment and disease-free survival
in a series of 137 patients. Journal of the American Academy of Dermatology. 2013;69:357-365.
Our Thoughts on the Rash
• Hot Tub
• Heparin induced thrombocytopenia rash
• Hypersensitivity reaction
• Hematomas
• B-Cell Lymphoma
• What is left???
Copyright © 2016
Reprinted from The Journal of the American College of Dermatology, www.jaad.org , 54, Perrinaud A, et al.
Bullous hemorrhagic dermatosis occurring at sites distant from subcutaneous injections of heparin:
Three cases, S5-S7, Copyright 2006,with permission from Elsevier.
Perrinaud A, et al.Bullous hemorrhagic dermatosis occurring at sites distant from subcutaneous injections of heparin: Three cases.
Journal of the American Academy of Dermatology. 2006;54: S5 - S7.
Govind B, et al. Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation.Hosp Pract. 2016;44:103-7.
doi: 10.1080/21548331.2016.1159908. Epub 2016 Mar 23.
Bullous Hemorrhagic Dermatosis
Govind B, et al. Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation.Hosp Pract. 2016;44:103-7.
doi: 10.1080/21548331.2016.1159908. Epub 2016 Mar 23.
LMWH Skin Reaction
• Rare skin manifestation of LMWH (enoxaparin)
•
•
Distant from the site of injection
Bullous blood filled lesions with no evidence of inflammatory
infiltrate, capillary thrombosis or evidence of vasculitis,
immunofluorescence testing negative
Govind B, et al. Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation.Hosp Pract. 2016;44:103-7.
doi: 10.1080/21548331.2016.1159908. Epub 2016 Mar 23.
Our Recommendations
 Literature not clear on stopping or continuing
LMWH anticoagulation.
 We recommend alternative DVT prophylaxis
for next long distance flight.
• Ambulation and exercise
• Hydration
Copyright © 2016
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