J Korean Med Sci.  2010 Sep;25(9):1390-1393. 10.3346/jkms.2010.25.9.1390.

Warfarin-Induced Penile Necrosis in a Patient with Heparin-Induced Thrombocytopenia

• Chang IH
• Ha MS
• Chi BH
• Kown YW
• Lee SJ

• KMID: 1785925
• DOI: http://doi.org/10.3346/jkms.2010.25.9.1390

Abstract

A 56-yr-old man with lung adenocarcinoma presented with subsegmental pulmonary thrombosis. Platelet count on presentation was 531x10(9)/L. The patient was anticoagulated with subcutaneous low molecular weight heparin (LMWH). Next day, oral anticoagulation was initiated with 5 mg of warfarin once daily with LMWH and LMWH was discontinued at third hospital day. On the third day of oral anticoagulation therapy, he complained of left leg swelling and prolonged painful penile erection of 24 hr-duration. His platelet count reached a nadir 164x10(9)/L at that time, and the patient had a deficiency of protein C and S, with an activity level of 16% and 20% of normal value. Warfarin was stopped and he underwent penile aspiration. The next day, left leg edema and penile erection was disappeared, but penile and glans penis necrosis was started. This case illustrates that processes underlying heparin-induced thrombocytopenia (HIT) may also underlie warfarin-induced skin necrosis.

Keyword

Penis; Necrosis; Warfarin; Heparin

MeSH Terms

Adenocarcinoma/complications/diagnosis
Anticoagulants/*adverse effects
Heparin/*adverse effects
Humans
Lung Neoplasms/complications/diagnosis
Male
Middle Aged
Necrosis
Penile Erection/drug effects
Penis/*pathology
Platelet Count
Protein C/analysis
Protein S/analysis
Pulmonary Artery
Thrombocytopenia/*chemically induced
Thrombosis/complications/diagnosis/drug therapy
Warfarin/*adverse effects

Figure

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  Fig. 1 Serial platelet counts relative to hospital day for a patient with metastatic lung adenocarcinoma being treated for pulmonary thrombosis and later found to develop anticoagulation-induced penile necrosis and HIT. Anticoagulant used per hospital day is shown as well. The patient developed priapism and penile necrosis by the 3rd days of warfarin administration.

• 

  Fig. 2 Penile necorsis lesion of a patient receiving systemic anticoagulation with low molecular weight heparin and warfarin. Skin distal half penile shaft and glans penis showed black discoloration with erythema after penile blood clot extraction due to priapsm (A). International normalized ratio (INR) at the time of appearance was 6.01 and the platelet count was 164×109/L. Results showed that the patient had a deficiency of protein C and S, with an activity level of 16% and 20% of normal value. The patient had a known diagnosis metastatic lung adenocarcinoma. Seven days after the initial event, physical findings showed distal half penile necrosis including glans penis and we performed partial penectomy (B).

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