RESUMEN
Skin necrosis and priapism are unusual complications of warfarin therapy. We report a teenager with warfarin-associated skin necrosis and priapism who was subsequently found to be a compound heterozygote for protein C deficiency and a heterozygote for the factor V Leiden mutation.
Asunto(s)
Anticoagulantes/efectos adversos , Erupciones por Medicamentos/etiología , Priapismo/inducido químicamente , Warfarina/efectos adversos , Adolescente , Erupciones por Medicamentos/complicaciones , Erupciones por Medicamentos/patología , Factor V/genética , Humanos , Masculino , Necrosis , Priapismo/complicaciones , Deficiencia de Proteína C/complicaciones , Trombofilia/genéticaRESUMEN
OBJECTIVES: To evaluate safety, efficacy, and outcome after combination thrombolytic and anticoagulant therapy. STUDY DESIGN: An open nonrandomized clinical protocol with prospective standardized monitoring and data collection. Children with a documented first episode of deep vein thrombosis were treated with urokinase 4400 U/kg load and per hour with unfractionated heparin at 10 U/kg/h. At 48 hours heparin infusions were increased to achieve a therapeutic level for 5 days. Children were given therapeutic warfarin for at least 3 months. Outcome was assessed at 48 hours and > or =1 year with history, physical examination, high-resolution imaging, and Doppler ultrasonography +/- impedance and photo plethysmography. RESULTS: Thirty-two children were treated. There was 1 thrombotic death, 1 nonfatal thrombus progression, and 1 pulmonary embolism. At 48 hours half of the children showed substantial clot lysis, and on follow-up these children had complete resolution and had no symptoms. Three children with poor early clot lysis had recurrent thromboemboli, pulmonary embolism, or both, 2 had limb pain and swelling, and 2 had asymptomatic swelling. Two children had minor bleeding, whereas systemic reactions were common. CONCLUSIONS: Combination therapy in children (urokinase and unfractionated heparin) was safe and efficacious. A prospective, randomized, controlled study in children is needed.
Asunto(s)
Anticoagulantes/uso terapéutico , Fibrinolíticos/uso terapéutico , Terapia Trombolítica , Trombosis de la Vena/tratamiento farmacológico , Adolescente , Anticoagulantes/efectos adversos , Niño , Preescolar , Quimioterapia Combinada , Femenino , Fibrinolíticos/efectos adversos , Estudios de Seguimiento , Humanos , Lactante , Masculino , Pletismografía/métodos , Estudios Prospectivos , Embolia Pulmonar/sangre , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/estadística & datos numéricos , Resultado del Tratamiento , Ultrasonografía , Trombosis de la Vena/sangre , Trombosis de la Vena/diagnóstico por imagenRESUMEN
Eleven infants initially seen in the neonatal period had levels of protein C suggestive of homozygous protein C deficiency but as an apparently acquired condition. Family studies failed to document parental carrier status, the clinical course was not typical of that reported with homozygous protein C deficiency, and protein C levels increased in all restudied infants, six of whom received heparin anticoagulation. No infant had evidence of vitamin K deficiency. Care is advised in the evaluation of infants with low levels of protein C. Parental blood studies, delayed testing, and serial assays can help to establish the correct diagnosis.