Bullous hemorrhagic dermatosis distant from the site of heparin injection

Concha-Garzón, M.J.; Sotomayor-Lopez, E; Solano-López, G.; Fraga, Jose Carlos; Argila, D. de

doi:10.5070/d32010024263

Cited by 10 publications

(11 citation statements)

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“…[39][40][41] Data of all previous reports included in the study and of our own case were compiled in Table 1. HBHD affected 44 men [1][2][3][4][5][6][7][8][9][10][11]13,17,19,21,23,24,[26][27][28][29][30][31][32][33][34]36 and 16 women, 1,2,6,12,14,22,25,29,35,36 with a male/female rate of 2.75. The age range was from 21 to 94 years, with an average of 70.8 and a median of 72 years.…”

Section: Resultsmentioning

confidence: 99%

“…The lapse of time between the start of heparin and the onset of skin lesion varied from 6 hours to 240 days, with an average of 17.3 days and a median of 7 days. In regard to the topography of the skin lesions, hands were affected in 16 patients, 1,[5][6][7]11,13,14,16,21,24,25,29,31,34 wrists in 1 patient, 24 forearms in 9 patients, 1,5,16,20,29,30,37,38 arms in 8 patients, 6,7,9,10,12,21,23,27 elbows in 1 patient, 20 upper extremities with no other specification in 10 patients, 2,17,18,24,26,28,36 feet in 8 patients, 6,11,12,29,34,35 ankles in 9 patients, 1,3,11,12,…”

Section: Resultsmentioning

confidence: 99%

“…In one case, the site of the lesion was not specified. 33 On histopathology, the level of the blister showed to be subcorneal in 10 patients, 2,3,8,9,13,17,18,29 intraepidermal in 30 patients, 1,[4][5][6]10,11,16,[21][22][23][24][25][26][27][28][29][30]33,36,37 subepidermal in 8 patients 6,7,14,20,29,35,38 , and both intraepidermal and subepidermal in 1 patient. 29 In 33 cases, there was no significant dermal inflammatory infiltrate.…”

Section: Resultsmentioning

confidence: 99%

“…1,29 Eosinophils were found within the dermal inflammatory infiltrate in 2 cases, 4,29 neutrophils in 2 cases, 5,21 and a mixture of eosinophils and neutrophils in other 2 cases. 3,14 In 11 cases, data about histopathologic features were not available. 5,7,12,15,19,22,31,32,34,36 Direct immunofluorescence was performed in 18 cases, all of them with negative results.…”

Section: Resultsmentioning

confidence: 99%

“…Perusal of photomicrographs provided in cases with subepidermal blisters depicts that, in 2 cases, the roof of the blister was formed only by the upper part of the epidermis, 29,38 whereas, in another, remnants of epidermal epithelial cells were present in the floor of the blister. 14 In the article by Roux et al, only a hemorrhagic suffusion in the dermis with no identifiable blister was pictured, whereas in other 3 publications, no photomicrograph is provided. 7,20,35 Another interesting feature of HBHD is that the blisters seem to be more long-standing and resistant to rupture than the ones seen in pemphigus foliaceus, an acantholytic antibody-mediated bullous dermatosis with similar levels of cleavage (intraepidermal or subcorneal).…”

Section: Discussionmentioning

confidence: 99%

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Heparin-Induced Bullous Hemorrhagic Dermatosis: A Report of an Exceptionally Exuberant Case and Literature Review

Almeida

Campos

Daxbacher

et al. 2021

The American Journal of Dermatopathology

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Introduction: Heparin-induced bullous hemorrhagic dermatosis (HBHD) is an unusual cutaneous adverse reaction to heparin characterized by acute onset of hemorrhagic bullae.Methodology: An exuberant case of HBHD is reported, and a revision of previously reported cases indexed on PubMed is provided. Cases were tabulated to the following parameters: sex, age, type of heparin and route of administration, associated medical procedure, number of days between heparin start and onset of lesions, site of the lesions, level of blister on histopathology, inflammatory infiltrate on histopathology, direct immunofluorescence findings, heparin-related intervention, number of days to resolution of skin lesions, associated hemorrhagic event, and outcome.Case report: A 21-year-old woman with end-stage renal disease was receiving intravenous unfractioned heparin (UFH) during hemodialysis section for the past 3 months. Four hours after using for the first time an arteriovenous fistula punctured on her right wrist, the patient noticed the onset of vesicles and blisters on the right forearm containing citrus or serohemorrhagic exudate, which became overt hemorrhagic in 24 hours. Histopathology depicted a nonacantholytic subcorneal blister containing erythrocytes and plasma without any significant dermal inflammatory infiltrate.Results: Sixty cases of HBHD were included. HBHD affected predominantly men, with a male/female rate of 2.75. The age range was from 21 to 94 years, with an average of 70.8 and a median of 72 years. Nine patients used UFH, and 54 patients used low molecular weight heparins (3 patients used both). The lapse of time between the start of heparin and the onset of skin lesion varied from 6 hours to 240 days, with an average of 17.3 days and a median of 7 days. Limbs were affected in most of the cases. The level of the blister was subcorneal in 10 patients, intraepidermal in 30, subepidermal in 8, and both intraepidermal and subepidermal in 1. In 33 cases, there was no significant dermal inflammatory infiltrate. Pure lymphocytic inflammatory infiltrate was present in 10 cases. Eosinophils were found within the dermal inflammatory infiltrate in 2 cases, neutro-phils in 2, and a mixture of eosinophils and neutrophils in other 2. Direct immunofluorescence was performed in 18 cases, all of them with negative results.Discussion: We hypothesize that mechanical trauma, skin fragility, and the anticoagulation effect of heparin might contribute concomitantly to the development of the lesions and speculate that subepidermal blisters in HBHD could be formed by rupture of the floor of a former intraepidermal blister.

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