Apixaban
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Apixaban Cutaneous leucocytoclastic vasculitis: case report
A 68-year-old woman developed cutaneous leucocytoclastic vasculitis during treatment with apixaban for atrial fibrillation. The woman, who had a history of hypertension, hyperlipidaemia and atrial fibrillation, presented to the hospital with a 4-day history of rash on bilateral lower extremity. She did not have pruritus, pain, fever or chills and her review of systems was otherwise negative. She had been started on apixaban [dosage and route not stated] a month prior to the presentation for atrial fibrillation. There were no other recent changes to her medications. Her other medications included atorvastatin and hydrochlorothiazide. She did not have any new environmental exposures or dietary changes. Physical examination showed diffuse palpable tender nonblanching violaceous coalescent macules and patches on both the thighs and calves with purple bullae overlying a patch on the left dorsal fifth toe and the right medial calf. The rest of the body was spared, and the remainder of examination was unremarkable. Complete blood count, including eosinophil count, comprehensive metabolic panel, urinalysis, erythrocyte sedimentation rate and CRP, were within the normal limits. Additional testing to rule out connective tissue diseases including components 3 and 4 levels, antinuclear antibodies, anti-Ro and anti-La antibodies, cytoplasmic antineutrophil antibodies and perinuclear antineutrophil antibodies were all negative. Infectious aetiologies including HIV, hepatitis C antibody, hepatitis B surface antigen, quantiFERONtuberculosis, urinary chlamydia and gonorrhoea testing was negative. She had also showed a normal results during the colonoscopy and mammogram, which were performed during the last year. Punch biopsy of the left shin was performed and demonstrated pandermal leucocytoclastic vasculitis with no medium vessel involvement. Direct immunofluorescence testing was performed within 4h of obtaining the biopsy specimen and showed strong granular deposition of IgA, IgM and complement component 3 within the dermal vessel walls consistent with leucocytoclastic vasculitis. Given that she had no other recent medication changes or allergen exposure, her rash was considered likely to be caused by apixaban. She was diagnosed with apixaban-induced cutaneous leucocytoclastic vasculitis after excluding other infectious, malignant and autoimmune causes. Consequently, the woman’s therapy with apixaban was replaced by warfarin. She was also treated with prednisone. Her rash resolved with cessation of the medication. Subsequently, she was discharged from the hospital. During follow-up at 1 month and 4 months later, a near resolution of the rash with minimal residual hyperpigmentation was noted. Khan M, et al. Apixaban-induced cutaneous leucocytoclastic vasculitis. BMJ Case Reports 13: No. 8, 24 Aug 2020. Available from: URL: http://doi.org/10.1136/ bcr-2020-237043
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