Disclosures: Nan Wang, MD: Nothing to disclose

Case Description: A 54-year old female with history of osteoarthritis underwent bilateral total knee replacement without complications. She was started on lovenox as deep vein thrombosis prophylaxis and was admitted to acute rehabilitation for physical and functional optimization. Ten days after starting lovenox, patient was found to have skin necrosis at the lovenox injection sites. She did not have thrombocytopenia or signs of bleeding, and her prothrombin time and partial thromboplastin time were both within normal range.

Setting: Tertiary Care Center

Patient: A 54-year old female with history of osteoarthritis

Assessment/Results: Due to clinical suspicion for heparin-induced thrombocytopenia (HIT), lovenox was discontinued immediately and fondaparinux was started. Both anti-heparin IgG antibody and serotonin assay were positive, and diagnosis of HIT was made. Skin biopsy was taken and showed thrombotic vasculopathy with minimal vasculitis. Patient was continued on anticoagulation for another 3 months after she was discharged from acute rehabilitation.

Discussion: HIT is a life-threatening complication in patients exposed to heparin (either unfractionated or low molecular weight heparin) and typically presents with thrombocytopenia, bleeding and thrombosis. HIT without thrombocytopenia is atypical and only occurs in 5% of patients with HIT. Skin necrosis can be the initial sign of HIT without thrombocytopenia and warrants additional hematology workup. Diagnosis is based on clinical signs and symptoms as well as the presence of anti-platelet factor 4 heparin antibody, and functional assays including serotonin release assay or heparin-induced platelet activation assay. When HIT is suspected, all forms of heparin should be discontinued immediately. Anticoagulation with a non-heparin anticoagulant such as direct thrombin inhibitors or direct oral anticoagulants should be started in patients with presumptive clinical diagnosis of HIT.

Conclusion: In patients exposed to heparin who develop skin necrosis, HIT should be suspected even in the absence of thrombocytopenia. Heparin should be discontinued immediately to prevent fatal thromboembolic complications.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2019

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/heparin-induced-skin-necrosis-in-the-absence-of-thrombocytopenia-atypical-presentation-of-heparin-induced-thrombocytopenia/