1. In the Hot Seat: What Is This Rash After Low-Molecular-Weight Heparin?
From the Publishers of
Consult Guys
In the Hot Seat: What Is This Rash After Low-Molecular-Weight Heparin?
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3. I know you guys have been around a long time and have seen everything
I know you guys have been around a long time and have seen everything! A patient is in my office now and I need your help.
Guys:
My patient is a 62-year-old man who had been vacationing in New Mexico at a health spa. He is in my office now with this weird rash on his hands and I cannot figure it out. It developed yesterday which was one day after he returned home.
He had 6 hot tub treatments for his psoriasis at the health spa. He has history of B cell lymphoma, hypertension, and DVT after a flight from China 2 years ago. Since then I prophylax him with LMWH for each long distance flight. For the recent flight he took enoxaparin 40mg, SC (abdominal site) for the flight out and the same dose for the return.
Enoxparin 40 mg prior to flight and on return flight
Meds: furosemide 40mg, synthroid 125 mcg,
(abdominal site)
PMHx: HBP, B-Cell Lymphoma (remission), DVT right fem-pop 2 yrs. ago
SHx: non smoker, no ETOH
PE: BP 120/70, P 78, R 12, T 98.6, Wt 78 kg
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4. 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: [PMID: ] doi: /

5. Case Labs: Hgb 12.4, Hct 38, WBC 8K Plts: 230K SCr 1, CrCl 70 cc/min,
LFTS Normal
PTT 30s, INR 1.1
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6. 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
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7. Heparin Induced Thrombocytopenia Skin Lesions
HIT
Only 2 doses of enoxaparin
Platelet count normal
Skin lesion not necrotic
Reprinted from The Lancet 380,
Schindewolf M, Heparin-Induced Skin Lesions, ,
Copyright 2012,with permission from Elsevier.
Schindewolf M, et al. Heparin-Induce Skin Lesions. Lancet 2012;380:

8. Hypersensitivity Reaction UFH & LMWHs
Areas at injection site are red and warm
Hive like skin reaction
Reprinted from The Lancet 380, Schindewolf M, Heparin-Induced Skin Lesions, ,
Copyright 2012,with permission from Elsevier.
Schindewolf M, et al. Heparin-Induce Skin Lesions. Lancet 2012;380:

9. Injection Site Hematomas

10. B-Cell Lymphoma Skin Lesions
Reprinted from The Journal of the American College of Dermatology, 69,
Servitje O, Primary cutaneous marginal zone B-cell lymphoma: Response to treatment
and disease-free survival in a series of 137 patients, , 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:

11. Our Thoughts on the Rash
Hot Tub
Heparin induced thrombocytopenia rash
Hypersensitivity reaction
Hematomas
B-Cell Lymphoma
What is left???
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12. Reprinted from The Journal of the American College of Dermatology, www
Reprinted from The Journal of the American College of Dermatology, , 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: / Epub 2016 Mar 23.

13. Bullous Hemorrhagic Dermatosis
Govind B, et al. Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation.Hosp Pract. 2016;44:103-7.
doi: / Epub 2016 Mar 23.

14. 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: / Epub 2016 Mar 23.

15. 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
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