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? COPYRIGHT © 2016, ALL RIGHTS RESERVED

Terms of Use The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement. Copyright © 2016

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 Copyright © 2016

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;44:103-7. [PMID: 26928382] doi:10.1080/21548331.2016.1159908

Case Labs: Hgb 12.4, Hct 38, WBC 8K Plts: 230K SCr 1, CrCl 70 cc/min, LFTS Normal PTT 30s, INR 1.1 Copyright © 2016

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 Copyright © 2016

Heparin Induced Thrombocytopenia Skin Lesions HIT Only 2 doses of enoxaparin Platelet count normal Skin lesion not necrotic Reprinted from The Lancet www.thelancet.com, 380, Schindewolf M, Heparin-Induced Skin Lesions, 1867-79, Copyright 2012,with permission from Elsevier. Schindewolf M, et al. Heparin-Induce Skin Lesions. Lancet 2012;380:1867-79.

Hypersensitivity Reaction UFH & LMWHs Areas at injection site are red and warm Hive like skin reaction Reprinted from The Lancet www.thelancet.com, 380, Schindewolf M, Heparin-Induced Skin Lesions, 1867-79, Copyright 2012,with permission from Elsevier. Schindewolf M, et al. Heparin-Induce Skin Lesions. Lancet 2012;380:1867-79.

Injection Site Hematomas

B-Cell Lymphoma Skin Lesions Reprinted from The Journal of the American College of Dermatology, www.jaad.org, 69, Servitje O, Primary cutaneous marginal zone B-cell lymphoma: Response to treatment and disease-free survival in a series of 137 patients, 357-365, 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;69:357-365.

Our Thoughts on the Rash Hot Tub Heparin induced thrombocytopenia rash Hypersensitivity reaction Hematomas B-Cell Lymphoma What is left??? Copyright © 2016

Reprinted from The Journal of the American College of Dermatology, www Reprinted from The Journal of the American College of Dermatology, www.jaad.org , 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: 10.1080/21548331.2016.1159908. Epub 2016 Mar 23.

Bullous Hemorrhagic Dermatosis Govind B, et al. Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation.Hosp Pract. 2016;44:103-7. doi: 10.1080/21548331.2016.1159908. Epub 2016 Mar 23.

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: 10.1080/21548331.2016.1159908. Epub 2016 Mar 23.

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 Copyright © 2016

Produced by and COPYRIGHT © 2016, ALL RIGHTS RESERVED