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Coumadin-induced cutaneous necrosis of the ear lobule
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This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
A 28 yr old female†, presented to the department of General Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India, in June 2017, was diagnosed to have Budd–Chiari syndrome (hepatic vein thrombosis) (Fig. 1) due to anti-phospholipid syndrome. She received low-molecular-weight heparin for five days followed by oral anticoagulant (OAC) acenocoumarol (2 mg). On the second day of starting OAC, the patient complained of pain and altered sensation in the right ear lobule followed by development of oedema and ecchymosis, which ulcerated and healed in a month (Fig. 2A-D). Her prothrombin time was normal. She was diagnosed to have coumadin-induced cutaneous necrosis (CICN), which affects 0.01–0.1% of the patients treated with OACs. CICN usually affects the areas with abundant subcutaneous fat such as the abdomen, buttocks, thighs, legs and breast in women and penis in men but rarely affects the ears.
- Contrast-enhanced computed tomography abdomen showing non-opacified right hepatic vein.
- (A) Right ear showing discolouration. (B) Lesion showing oedema on the third day. (C) Lesion showing ulceration on the eighth day. (D) Healed lesion on day 30.
Acenocoumarol was discontinued, and low-molecular-weight heparin was continued with local wound care. Patients with protein C deficiency, anti-thrombin III deficiency and positive anti-phospholipid antibodies (functional protein C and S deficiency) are prone to develop CICN. She underwent percutaneous transcutaneous hepatic vein angioplasty for hepatic vein recanalization and ultimately succumbed three months later due to poor medication adherence.
CICN should not be mistaken for a simple haematoma and ignored, since failure to identify the lesion early can end up with severe skin necrosis. Starting OACs after heparin, gradually building up the dose and avoiding large fluctuations of International Normalised Ratio (INR) may help avoid the development of such lesions in prone individuals.
Conflicts of Interest: None.
