BMJ Case Reports 2017; doi:10.1136/bcr-2016-218015
  • Novel treatment (new drug/intervention; established drug/procedure in new situation)

Anticoagulation therapy for thromboembolism prevention: a case of warfarin-induced skin necrosis in the setting of protein C deficiency

  1. Dennis Bloomfield3
  1. 1Department of Anatomical Sciences, St. George’s University School of Medicine, True Blue, Grenada
  2. 2Department of Medicine, Richmond University Medical Center, Staten Island, New York, USA
  3. 3Department of Medicine, Richmond University Medical Center, Staten Island, New York, USA
  1. Correspondence to Daryl Ramai, dramai{at}
  • Accepted 14 April 2017
  • Published 12 May 2017


Patients with protein C deficiency are at increased risk for thrombolic diseases. Non-vitamin K antagonist anticoagulant options should be considered in patients with warfarin-induced skin necrosis (WISN) in the setting of protein C. We report a 41-year-old African American male patient with WISN and protein C deficiency who was treated with rivaroxaban followed by dabigatran. After 1 month on rivaroxaban, he began experiencing blood in his stools, unrelenting pain in his lower extremities, found it difficult to obtain medication despite having insurance and as a result did not maintain compliance. He was then assessed at the hospital, symptomatically treated and discharged on dabigatran. After 6 weeks, he reported symptomatic relief and less side effects. This case involved a head-to-head clinical comparison of rivaroxaban and dabigatran as alternatives to warfarin anticoagulation therapy.


  • Contributors JL and DR wrote the manuscript. DB and DR edited the manuscript. JL and RA identified the case and supervised the treatment of the patient.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Register for free content

The full text of all Editor's Choice articles and summaries of every article are free without registration

The full text of Images in ... articles are free to registered users

Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource

Don't forget to sign up for content alerts so you keep up to date with all the case reports as they are published, and let us know what you think by commenting on the Editor's blog

Navigate This Article