Leukocytoclastic vasculitis (LCV) is a small vessel vasculitis characterized by palpable purpura of the lower extremities and histological findings of leukocytoclasis; or vascular damage caused by neutrophilic infiltration. LCV is typically idiopathic, though infections and medications are known triggers. The medication apixaban, however, has hardly been attributed as the cause of cutaneous LCV.
Apixaban is a direct oral anticoagulant that selectively and reversibly inhibits factor Xa. Common adverse reactions include ecchymoses, hematomas, menorrhagia, epistaxis, and more serious major bleeds. Apixaban related immune-complex small-vessel vasculitis is uncommon. We present a rare case of apixaban induced leukocytoclastic vasculitis.
A 72-year-old male with a significant past medical history of a recently diagnosed deep venous thrombosis of the left lower extremity presented with a new-onset rash on both legs for 5 days. He described the rash as red, non-blanching, and raised; occurring approximately 1 week after starting apixaban therapy. On exam, the rash was palpable and non-tender; extending from the dorsum of the feet to the mid-thighs bilaterally.
An extensive laboratory workup was negative. Three skin punch biopsies were performed which revealed deposition of IgA in the superficial blood vessels with perivascular infiltration of leukocytes.
The rash was ultimately attributed to apixaban which was discontinued. The rash gradually improved over the course of two weeks and he was eventually anticoagulated with dabigatran without any adverse events.
The diagnosis of LCV is established by skin biopsy and management involves discontinuation of the offending agent with or without addition of steroids or another immunosuppressive agent. Patients on apixaban who developed LCV have been successfully anticoagulated with other medications without adverse events.
Keywords: Apixaban, Anticoagulation, Factor 10a Inhibitor, Leukocytoclastic, Palpable purpura, Rash, Vasculitis