Intracranial hemorrhage with fatal outcome in a patient with heparin induced bullous hemorrhagic dermatosis

Yürekli, Aslan; Çalışkan, Ercan; Doğan, Deniz

doi:10.4274/turkderm.26779

Cited by 2 publications

(13 citation statements)

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“…Of the 91 cases presented, there were four cases that had bleeding complications, two with fatal intracranial hemorrhage [ 2 , 28 ]. Available coagulation tests were normal in these patients at the onset of anticoagulation.…”

Section: Discussionmentioning

confidence: 99%

“…In Perrinaud et al [ 2 ], the bleeding event occurred with a supratherapeutic INR. In Yurekli et al [ 28 ], the fatal event occurred after continuing enoxaparin, but the bullous lesions had resolved at the time of death. The documented rate of intracranial hemorrhage in the CLOT trial while using LMWH for a 6-month study period was one out of 338 [ 40 ].…”

Section: Discussionmentioning

confidence: 99%

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Bullous hemorrhagic dermatosis is an under-recognized side effect of full dose low-molecular weight heparin: a case report and review of the literature

et al. 2018

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Bullous hemorrhagic dermatosis (BHD) is a systemic side-effect of low molecular weight heparin, characterized by multiple intra-epidermal hemorrhages distant from the site of injection. There have been several small case series and literature reviews on BHD, but none have captured a complete set of reported patients. We sought to describe a case of BHD with late diagnosis and completely summarize the existing English and Spanish literature with searches of Pubmed, Scopus, Ovid Embase and Ovid Medline. After narrowing to 33 relevant reports, we describe 90 reported cases worldwide from 2004 to 2017, in addition to a new case from our institution as a means of comparison. We found that BHD was common in elderly men (mean age 72 ± 12; male:female, 1.9:1) and typically occurred within 7 days of administration of anticoagulation (median 7 days ± 6.4) usually with enoxaparin use (66% of cases). Lesions occurred primarily on the extremities only (67.9% of cases). Coagulation testing was most often normal before administration, and the majority of patients had coagulation testing in therapeutic range during treatment. Most practitioners stopped anticoagulation if continued therapeutic intervention was no longer required (57% of cases), or changed therapy to another anticoagulation if continued treatment was required (14.3% of cases). Therapy was continued outright in 23% of patients. The lesions usually resolved within 2 weeks (mean days, 13.0 ± 7.4). There was no difference in time to resolution between patients who continued the culprit anticoagulant or changed to a different anticoagulant, and those who discontinued anticoagulation altogether (13.9 days vs. 12.1, p = 0.49). Four deaths have been reported in this clinical context, two specified as intracranial hemorrhage. These deaths were unrelated to the occurrence of BHD. Continuation of low-molecular weight heparins appeared to be safe in patients with BHD.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Bullous hemorrhagic dermatosis is an under-recognized side effect of full dose low-molecular weight heparin: a case report and review of the literature

et al. 2018

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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%

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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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Intracranial hemorrhage with fatal outcome in a patient with heparin induced bullous hemorrhagic dermatosis

Cited by 2 publications

References 4 publications

Bullous hemorrhagic dermatosis is an under-recognized side effect of full dose low-molecular weight heparin: a case report and review of the literature

Bullous hemorrhagic dermatosis is an under-recognized side effect of full dose low-molecular weight heparin: a case report and review of the literature

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

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