Correspondence
8 Arrington JH III, Lockman DS. Thermal keratoses and squamous cell carcinoma in situ associated with erythema ab igne. Arch Dermatol 1979; 115: 1226–1228. 9 Jones CS, Tyring SK, Lee PC, et al. Development of neuroendocrine (Merkel cell) carcinoma mixed with
High-dose vitamin K: a remedy for excessive bleeding induced by warfarin
Editor, The toxic dose of warfarin is highly variable. Generally, the chronic use of a lower dose (2–5 mg/day) can lead to more significant anticoagulation than a single higher dose (10–20 mg).1 We report a patient with a 7-year history of warfarin use in whom high-dose vitamin K therapy for uncontrolled bleeding after surgery for skin cancer was required. An 82-year-old man presented with a solitary, 0.7 9 0.9 cm hyperpigmented tumor on the right infraorbital area that had become apparent eight months previously (Fig. 1a). The patient had been taking warfarin for the previous seven years to treat chronic atrial fibrillation. Basal cell carcinoma was confirmed after biopsy, and warfarin was stopped one week prior to surgery. A laboratory examination on the day of surgery showed the patient’s white blood cell count to be 4920/ ll, hemoglobin to be 10 g/dl, and platelet count to be 93,000/ll. Prothrombin time (PT) had been normalized to 1.14 (international normalized ratio [INR]), and partial thromboplastin time (PTT) was 32.6 s (normal range: 27.9~41.6 s). The tumor margin was cleared in two stages of Mohs micrographic surgery, and the remaining 1.5 9 2.5 cm defect (Fig. 1b) was repaired using an inferiorly based rotation flap. The patient returned the following day with uncontrolled bleeding (Fig. 2a). He was admitted for con-
(a)
squamous cell carcinoma in erythema ab igne. Arch Dermatol 1988; 124: 110–113. 10 Wharton J, Roffwarg D, Miller J, et al. Cutaneous marginal zone lymphoma arising in the setting of erythema ab igne. J Am Acad Dermatol 2010; 62: 1080–1081.
servative care, but compression dressing failed to stop the bleeding. The stitches were removed and electrocoagulation was attempted, but blood continued to ooze from all over the wound bed without specific vascular focus (Fig. 2b). On postoperative day 4, the patient’s hemoglobin level fell to 7.9 g/dl, and his platelet count was 106,000/ll. Two units of packed red blood cells and three units of fresh frozen plasma were transfused. Tranexamic acid (750 mg/day) and 10 mg of intramuscular vitamin K were administered, after which bleeding seemed to stop temporarily. However, bleeding resumed on postoperative day 12 when flap closure was attempted. Therefore, the flap was left to close secondarily. High-dose vitamin K at 30 mg/day, with a gradual increase to 50 mg and 70 mg on day 3, was started after hematology consultation. Six packs of platelets were also given. Bleeding stopped on the third day of high-dose vitamin K therapy, and thus the dose was tapered gradually over the course of the next three days. Warfarin at 2 mg was resumed seven days later, and the flap healed with an acceptable cosmetic outcome (Fig. 2c). Despite demonstrating a normal INR value on the day of surgery, the patient suffered from uncontrolled bleeding for two weeks. Some studies support the opinion that, despite normal preoperative INR values, patients who have been on long-term anticoagulation therapy should be considered at risk for postoperative bleeding.2,3 Koc et al. compared findings in 16 patients on longterm warfarin therapy with those in 15 control patients.2
(b)
Figure 1 (a) An 82-year-old man demonstrates a solitary, 0.7 9 0.9-cm, hyperpigmented tumor with central ulceration on the right infraorbital area, which became apparent 8 months prior to presentation. (b) A 1.5 9 2.5-cm defect remained after two stages of Mohs micrographic surgery ª 2014 The International Society of Dermatology
International Journal of Dermatology 2014, 53, e347–e366
e355
e356
Correspondence
(a)
(c)
(b)
Figure 2 (a) On postoperative day 1, the patient returned to the hospital with uncontrolled bleeding and swelling. (b) On postoperative day 2, stitches were removed and electrocoagulation was attempted; however, blood continued to ooze from all over the wound bed. (c) During the 12-month follow-up, the patient showed no signs of further bleeding and the flap healed with an acceptable cosmetic outcome
The mean standard deviation duration of warfarin treatment was 64.1 54.9 months, and patients with INR values of < 1.5 were regarded as candidates for surgery. However, a significant reduction in postoperative hemoglobin levels was observed in the warfarin group in comparison with the control group (P < 0.05). Similarly, increased postoperative bleeding rates in patients on longterm warfarin were reported by Varkarakis et al.3 Warfarin was stopped to reduce the INR to 1.5, but patients on chronic warfarin more often required transfusion (24.0% vs. 5.2%; P < 0.005) and were more likely to demonstrate postoperative bleeding (8.0% vs. 0.9%; P < 0.05) than patients who were not using chronic anticoagulation.3 Given these data and the cessation of bleeding initiated by a high-dose vitamin K infusion, the present patient can be considered to have demonstrated an unexpected effect of chronic warfarin use. In summary, clinicians should remain aware that basic parameters of coagulation are not always accurate indicators of the likelihood of bleeding events.
Byung Ho Oh, MD Kee Yang Chung, MD, PhD Department of Dermatology Severance Hospital, Cutaneous Biology Research Institute Yonsei University College of Medicine Seoul South Korea E-mail: [email protected]
References 1 Piatkov I, Rochester C, Jones C, et al. Warfarin toxicity and individual variability – clinical case. Toxins (Basel) 2010; 2: 2584–2592. 2 Koc U, Bostanci EB, Karaman K, et al. Basic hemostatic parameters in patients with longterm oral anticoagulation undergoing cholecystectomy. J Laparoendosc Adv Surg Tech A 2011; 21: 417–425. 3 Varkarakis IM, Rais-Bahrami S, Allaf ME, et al. Laparoscopic renal–adrenal surgery in patients on oral anticoagulant therapy. J Urol 2005; 174: 1020–1023.
Hong Sun Jang, MD Mi Ryung Roh, MD, PhD
Palpebral sporotrichosis
Sporotrichosis is a subcutaneous mycosis caused by the dimorphic fungus, Sporothrix schenckii, which is found worldwide, particularly in certain temperatures and tropical climates. Classically, infection occurs after inoculation of the organism into the skin by abrasion with contaminated soil, hay, thorns, decaying wood, and corn stalk. The main clinical entities include lymphocutaneous, fixed cutaneous, extracutaneous, pulmonary, and disseminated International Journal of Dermatology 2014, 53, e347–e366
forms. Sporotrichosis in children is rare, although fixed cutaneous sporotrichosis is more common, and the face is a frequent location for infection.1–5 However, ocular sporotrichosis in children is very rarely reported.6–8 Herein, we report a new case in a child. A 3-year-old boy presented with a 3-month history of an enlarging, nontender, erythematous plaque on the left lower eyelid. The lesion started as a painless papule and progressed to plaque. Physical examination revealed an ª 2014 The International Society of Dermatology
8 Arrington JH III, Lockman DS. Thermal keratoses and squamous cell carcinoma in situ associated with erythema ab igne. Arch Dermatol 1979; 115: 1226–1228. 9 Jones CS, Tyring SK, Lee PC, et al. Development of neuroendocrine (Merkel cell) carcinoma mixed with
High-dose vitamin K: a remedy for excessive bleeding induced by warfarin
Editor, The toxic dose of warfarin is highly variable. Generally, the chronic use of a lower dose (2–5 mg/day) can lead to more significant anticoagulation than a single higher dose (10–20 mg).1 We report a patient with a 7-year history of warfarin use in whom high-dose vitamin K therapy for uncontrolled bleeding after surgery for skin cancer was required. An 82-year-old man presented with a solitary, 0.7 9 0.9 cm hyperpigmented tumor on the right infraorbital area that had become apparent eight months previously (Fig. 1a). The patient had been taking warfarin for the previous seven years to treat chronic atrial fibrillation. Basal cell carcinoma was confirmed after biopsy, and warfarin was stopped one week prior to surgery. A laboratory examination on the day of surgery showed the patient’s white blood cell count to be 4920/ ll, hemoglobin to be 10 g/dl, and platelet count to be 93,000/ll. Prothrombin time (PT) had been normalized to 1.14 (international normalized ratio [INR]), and partial thromboplastin time (PTT) was 32.6 s (normal range: 27.9~41.6 s). The tumor margin was cleared in two stages of Mohs micrographic surgery, and the remaining 1.5 9 2.5 cm defect (Fig. 1b) was repaired using an inferiorly based rotation flap. The patient returned the following day with uncontrolled bleeding (Fig. 2a). He was admitted for con-
(a)
squamous cell carcinoma in erythema ab igne. Arch Dermatol 1988; 124: 110–113. 10 Wharton J, Roffwarg D, Miller J, et al. Cutaneous marginal zone lymphoma arising in the setting of erythema ab igne. J Am Acad Dermatol 2010; 62: 1080–1081.
servative care, but compression dressing failed to stop the bleeding. The stitches were removed and electrocoagulation was attempted, but blood continued to ooze from all over the wound bed without specific vascular focus (Fig. 2b). On postoperative day 4, the patient’s hemoglobin level fell to 7.9 g/dl, and his platelet count was 106,000/ll. Two units of packed red blood cells and three units of fresh frozen plasma were transfused. Tranexamic acid (750 mg/day) and 10 mg of intramuscular vitamin K were administered, after which bleeding seemed to stop temporarily. However, bleeding resumed on postoperative day 12 when flap closure was attempted. Therefore, the flap was left to close secondarily. High-dose vitamin K at 30 mg/day, with a gradual increase to 50 mg and 70 mg on day 3, was started after hematology consultation. Six packs of platelets were also given. Bleeding stopped on the third day of high-dose vitamin K therapy, and thus the dose was tapered gradually over the course of the next three days. Warfarin at 2 mg was resumed seven days later, and the flap healed with an acceptable cosmetic outcome (Fig. 2c). Despite demonstrating a normal INR value on the day of surgery, the patient suffered from uncontrolled bleeding for two weeks. Some studies support the opinion that, despite normal preoperative INR values, patients who have been on long-term anticoagulation therapy should be considered at risk for postoperative bleeding.2,3 Koc et al. compared findings in 16 patients on longterm warfarin therapy with those in 15 control patients.2
(b)
Figure 1 (a) An 82-year-old man demonstrates a solitary, 0.7 9 0.9-cm, hyperpigmented tumor with central ulceration on the right infraorbital area, which became apparent 8 months prior to presentation. (b) A 1.5 9 2.5-cm defect remained after two stages of Mohs micrographic surgery ª 2014 The International Society of Dermatology
International Journal of Dermatology 2014, 53, e347–e366
e355
e356
Correspondence
(a)
(c)
(b)
Figure 2 (a) On postoperative day 1, the patient returned to the hospital with uncontrolled bleeding and swelling. (b) On postoperative day 2, stitches were removed and electrocoagulation was attempted; however, blood continued to ooze from all over the wound bed. (c) During the 12-month follow-up, the patient showed no signs of further bleeding and the flap healed with an acceptable cosmetic outcome
The mean standard deviation duration of warfarin treatment was 64.1 54.9 months, and patients with INR values of < 1.5 were regarded as candidates for surgery. However, a significant reduction in postoperative hemoglobin levels was observed in the warfarin group in comparison with the control group (P < 0.05). Similarly, increased postoperative bleeding rates in patients on longterm warfarin were reported by Varkarakis et al.3 Warfarin was stopped to reduce the INR to 1.5, but patients on chronic warfarin more often required transfusion (24.0% vs. 5.2%; P < 0.005) and were more likely to demonstrate postoperative bleeding (8.0% vs. 0.9%; P < 0.05) than patients who were not using chronic anticoagulation.3 Given these data and the cessation of bleeding initiated by a high-dose vitamin K infusion, the present patient can be considered to have demonstrated an unexpected effect of chronic warfarin use. In summary, clinicians should remain aware that basic parameters of coagulation are not always accurate indicators of the likelihood of bleeding events.
Byung Ho Oh, MD Kee Yang Chung, MD, PhD Department of Dermatology Severance Hospital, Cutaneous Biology Research Institute Yonsei University College of Medicine Seoul South Korea E-mail: [email protected]
References 1 Piatkov I, Rochester C, Jones C, et al. Warfarin toxicity and individual variability – clinical case. Toxins (Basel) 2010; 2: 2584–2592. 2 Koc U, Bostanci EB, Karaman K, et al. Basic hemostatic parameters in patients with longterm oral anticoagulation undergoing cholecystectomy. J Laparoendosc Adv Surg Tech A 2011; 21: 417–425. 3 Varkarakis IM, Rais-Bahrami S, Allaf ME, et al. Laparoscopic renal–adrenal surgery in patients on oral anticoagulant therapy. J Urol 2005; 174: 1020–1023.
Hong Sun Jang, MD Mi Ryung Roh, MD, PhD
Palpebral sporotrichosis
Sporotrichosis is a subcutaneous mycosis caused by the dimorphic fungus, Sporothrix schenckii, which is found worldwide, particularly in certain temperatures and tropical climates. Classically, infection occurs after inoculation of the organism into the skin by abrasion with contaminated soil, hay, thorns, decaying wood, and corn stalk. The main clinical entities include lymphocutaneous, fixed cutaneous, extracutaneous, pulmonary, and disseminated International Journal of Dermatology 2014, 53, e347–e366
forms. Sporotrichosis in children is rare, although fixed cutaneous sporotrichosis is more common, and the face is a frequent location for infection.1–5 However, ocular sporotrichosis in children is very rarely reported.6–8 Herein, we report a new case in a child. A 3-year-old boy presented with a 3-month history of an enlarging, nontender, erythematous plaque on the left lower eyelid. The lesion started as a painless papule and progressed to plaque. Physical examination revealed an ª 2014 The International Society of Dermatology
