Warfarin-induced Venous Limb Gangrene

Go straight to your doctor if this shows up, You did hear about this side effect when you started didn't you? Its different that the purple toe.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509881/

Abstract

Warfarin is a commonly used anticoagulant that has been associated with several significant cutaneous side effects, most notably warfarin-induced skin necrosis. A lesser known adverse reaction to warfarin is warfarin-induced venous limb gangrene. Both cutaneous adverse effects share the same pathophysiology, but are clinically quite different. The majority of cases of warfarin-induced venous limb gangrene has been in patients with cancer or heparin-induced thrombocytopenia. However, other hypercoagulable disease states, such as the antiphospholipid antibody syndrome, can be associated with venous limb gangrene. In order to increase recognition of this important condition, the authors report a case of warfarin-induced venous limb gangrene in a patient with presumed antiphospholipid antibody syndrome and review the literature on warfarin-induced venous limb gangrene.

Warfarin is a commonly used anticoagulant that has been associated with several significant cutaneous side effects. The authors report a case of warfarin-induced venous limb gangrene in a patient with presumed antiphospholipid antibody syndrome (APS). Warfarin-induced venous limb gangrene is a distinct entity from warfarin-induced skin necrosis. Due to its infrequency and the fact that it presents much differently than warfarin-induced skin necrosis, physicians may dismiss the fact that warfarin is the cause of a patient’s necrosis. For this reason, it is important to recognize this as a separate clinical disease from warfarin-induced skin necrosis with similar underlying pathophysiology. This report of warfarin-induced venous limb gangrene is intended to increase the index of suspicion for this rare drug reaction whose effective treatment requires early diagnosis.

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CASE REPORT

A 45-year-old man with a history of deep vein thrombosis (DVT) and pulmonary embolus (PE) presented to his local hospital with bilateral foot pain. He was immediately transferred to the university hospital for treatment of cyanotic toes concerning for bilateral critical limb ischemia. The patient’s medical history included chronic obstructive pulmonary disease, alcohol abuse, seizure disorder, atrial fibrillation, and nonischemic cardiomyopathy. Notably, three months prior to presentation, he had been hospitalized with a large DVT and PE. He had an inferior vena cava filter placed and was prescribed warfarin therapy. The patient’s other home medications included phenytoin, diltiazem, and an albuterol inhaler.

On arrival to the hospital, the patient was admitted to the medical intensive care unit due to altered mental status and acute respiratory failure requiring intubation and mechanical ventilation. The patient’s international normalized ratio (INR) at admission was 14.1 (normal 0.8–1.2), PTT was 46 seconds (normal 24–34 seconds), and platelets were 74,000/µL (normal 150,000–450,000/µL). Warfarin was held and vitamin K and fresh frozen plasma were administered. Vascular surgery personnel assessed the patient on arrival and did not find any evidence for critical limb ischemia. Easily palpable bilateral dorsalis pedis and posterior tibial pulses were found on exam. Dermatology was then consulted for assessment of the patient’s toes.

On dermatological exam, sharply defined, confluent, noninflammatory irregular purpura were present involving all 10 toes, bilateral distal dorsal feet, and bilateral distal soles with several overlying large hemorrhagic bullae (Figures 1A–1C). Additional tense intact hemorrhagic and nonhemorrhagic bullae on nonerythematous base were noted on otherwise uninvolved more proximal foot and ankle. There was no appreciable livedo reticularis. Palpable pulses were noted in bilateral lower extremities. Hands were not involved. 

Nasty looking pictures at the link.