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Skin necrosis at injection site: case report A 73-year-old woman developed skin necrosis at injection site during anticoagulation therapy with enoxaparin-sodium. The woman, who had a history of heart failure, type 2 diabetes mellitus, atrial fibrillation, myelodysplastic syndrome and refractory anaemia was admitted for the treatment of chronic digital ischaemia of the left foot and cellulitis. Her concomitant medications included warfarin, metformin, valsartan, nebivolol, furosemide and vildagliptin. After admission, she was also diagnosed with acute bacterial skin and skin structure infection (ABSSI). Therefore, she started receiving vancomycin and piperacillin/tazobactam. Additionally, warfarin was switched to SC enoxaparin-sodium [enoxaparin] 12000 IU/day for anticoagulation. On the day 11 of hospitalisation, she presented with two erythematous painful lesions at enoxaparin-sodium injection sites on the right arm and at the abdominal wall. Initially, the lesions were attributed to heparin injection site haematomas, but following 48–72 hours, the lesions transforms into blisters with necrosis, which were starting from the center and peripherally progressing. Additionally, new lesions also appeared at the injection sites. Therefore, differential diagnoses made with heparininduced thrombocytopenia (HIT)-associated skin necrosis and warfarin-induced skin necrosis and hematoma. Upon admission, her platelet count was 337 × 109 /L and on day 11 it increased to 453 × 109/L. Initially, she was receiving warfarin, but upon admission, the prothrombin time was slightly prolonged with INR. HIT was excluded because of low 4Ts score (no thrombocytopenia and 2 points for skin necrosis). The lesions were initially erythematous and similar to injection site haematomas. However, they quickly developed into necrotic blisters. After excluding other diagnostic parameters and based on the clinical characteristics of the lesions, a confirmed diagnosis of enoxaparin sodium-induced skin necrosis at injection site was made. [duration of treatment to reaction onset not stated]. On day 14, the woman stopped enoxaparin-sodium and started fondaparinux-sodium. Following this, no new lesions appeared, but the initial lesions developed into necrotic ulcers. Meanwhile, she underwent amputation of her third, fourth and firth toes for chronic digital ischaemia of the left foot. She was discharged home without any further complications. She was continued on fondaparinux sodium and warfarin was scheduled to switch back a week after discharge. At 2 months of follow-up, the necrotic areas of the abdomen were healed completely, but only a small ulcer on right arm lesion was noted. Tampaki M, et al. Enoxaparin-induced skin necrosis without heparin-induced thrombocytopenia. Archives of Hellenic Medicine 37: 532-535, No. 4, Jun 2020. Available from: 803499362 URL: http://www.mednet.gr/archives/

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Reactions 5 Sep 2020 No. 1820