Sepsis as a cause of acquired Protein C and Protein S deficiency- A case report and literature review
AbstractWarfarin Induced Skin Necrosis is a well-known complication in patients being started on warfarin without adequate bridging . The mechanism is thought to be due to protein C deficiency . We present a rather unusual cause of protein C deficiency due to sepsis resulting in warfarin induced skin necrosis. 43 year old lady who has been on chronic warfarin therapy secondary to anti phospholipid syndrome was admitted to the hospital for acute ischemic cerebellar stroke. Warfarin was held due to acute thrombocytopenia. She was discharged after restarting the warfarin. She presented back with septic shock due to pneumonia. She was found to have multiple necrotic areas consistent with skin necrosis. Unfortunately, patient died due to multi organ failure despite goal directed therapy. This case demonstrates the importance of recognizing the sepsis as an acquired cause of protein C deficiency.
2. Horn J, Danziger L, David R: Warfarin –induced skin necrosis: Report of four cases, Am J Hosp Pharm 38: 1763-1768, 1981
3. McGehee WG, Klotz TA, Epstein DJ, Rapaport SI. Coumarin necrosis associated with hereditary protein deficiency. Ann. Intern. Med 1984; 100:59-60
4.Rose VL, Kwaan HC, Williamson K, Hoppensteadt D, Walenga J, Fareed J. Protein C antigen deficiency and warfarin necrosis. Am. J. Clin. Pathol. 1986; 86:653-5
5.Presgrave P, Ma D. Genetic predisposition to venous thromboembolism: moleculer basis and a practical guide to management.Aust.NZ J.Phleb. 2000; 4: 39-45
6. Taher A, Shamsseddine A, Saghir N, Seoud M, Mourad F, Dabajah B, Khlil A. Acquired protein C deficiency following cisplatinum-nevelbine administration for locally advanced breast cancer. Case report. Eur.J.Gynaecol.Oncol. 1999; 20:325-4
7. Feffer SE, Carmosino LS, Fox RL. Acquired protein C deficiency in patients with breast cancer receiving cyclophosphamide, methotrexate, and 5-fluorouracil. Cancer 1989; 63:1303-7
8. Fisher JJ, Yan SB. Protein C levels as a prognostic indicator of outcome in sepsis and related diseases. Crit. Care. Med. 2000:28:49-56
9. Yan SB, Helterbrand JD. Low levels of protein C are associated with poor outcome in severe sepsis. Chest 2001; 120:915-22
10.Ruiz-Arguelles GJ, Ruiz-Arguelles A, Deleze M, Alarcon-Segovia D. Acquired protein C deficiency in a patient with primary antiphospholipid syndrome. Relationship to reactivity of anticardiolipin antibody with thrombomodulin. J. Rheumatol. 1989; 16:381-5
11. Korsten S, Reis HE. Erworbener Protein- C-Mangel bei Colitis ulceros. Ursache thromboembolischer Komplikationen. Dtsch. Med. Wochenschr 1992; 117:419-24 (English abstract)
12. Mitchell CA, Rowell JA, Hau L, Young JP, Salem HH. A fatal thrombotic disorder associated with an acquired inhibitor of protein C. N Engl J Med. Dec 24 1987; 317(26): 1638-42.
13.Argaud L, Guerin C, Thomas L, Fournier G. Extensive coumarin –induced skin necrosis in a patient with acquired protein C deficiency. Intensive Care Med. 2001; 27:1555
14. Kurosh Parsi, Ian Younger and John Gallo. Warfarin induced skin necrosis associated with acquired protein C deficiency. Australian Journal of Dermatology; 2005; 44, 57-61
JNMA allow to read, download, copy, distribute, print, search, or link to the full texts of its articles and allow readers to use them for any other lawful purpose. The author(s) are allowed to retain publishing rights without restrictions. The JNMA work is licensed under a Creative Commons Attribution 4.0 International License. More about Copyright Policy.