This is skin necrosis associated with heparin induced thrombocytopenia (HIT) on the abdomen of a woman in her 50s (fig 1). This left sided painful skin necrosis occurred at the site of a subcutaneous dalteparin (low molecular weight heparin) injection 13 days after mitral valve replacement. On postoperative day 13 the patient’s platelet count fell to 56×109/L from a preoperative value of 282×109/L (normal range 140-400×109/L). The postoperative platelet count had been in the normal range until postoperative day seven but from then until day 13 it drifted downwards to a low of 56×109/L. Thereafter it gradually increased to reach the normal range four days after starting argatroban. Platelet factor 4 IgG enzyme linked immunosorbent assay for HIT was positive. Intravenous treatment with the thrombin inhibitor argatroban was started and warfarin introduced. The lesion was treated in a similar way to a second degree burn, with antiseptic dressings and regular…
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