Leukocytoclastic Vasculitis Associated with a New Anticoagulant: Rivaroxaban

A 28-year-old man who was being treated with diltiazem (60 mg/ day) and oral methylprednisolone (32 mg on alternate days) (6th month of Pozzi protocol [1]) for IgA nephropathy was admitted to our hospital with bilateral lower extremity non-blanching palpable purpura that occurred 10 days following the addition of 20 mg of rivaroxaban once daily for acute deep venous thrombosis in the right popliteal vein by another physician. There was no significant finding in the physical examination except for purpura. The complete blood count, metabolic panel, urine analysis, coagulation studies, infectious serologies, rheumatologic work-up, and serum immunoglobulin E level were all within normal limits. Rivaroxaban was replaced with subcutaneous enoxaparin sodium at 6000 IU twice a day, and the skin lesions disappeared within 1 week. Two weeks later, the patient was prescribed rivaroxaban at 10 mg a day again by the same physician who was following the patient for deep venous thrombosis because of the rarity of LCV due to rivaroxaban in the literature. Bilateral lower extremity purpura (Figure 1) reoccurred within 3 days of retreatment and a skin biopsy revealed neutrophil-predominant infiltrations within and surrounding the dermal small vessels, nuclear dust, vessel wall damage, erythrocyte extravasation, and fibrin deposition concurrent with vasculitis. Rivaroxaban was discontinued and enoxaparin was administered again, and the skin lesions resolved. The patient was in a clinically steady state for IgA nephropathy during the two episodes of vasculitis.