Heparin Induced Eczematous Drug Reaction

The process falls under the general rubric of an eczematous dermatitis being subacute in nature. A delayed hypersensitivity reaction is the probable basis. An immunologic response to a distant cutaneous stimulus is possible although certain drugs can cross react with topical medicament to which the patient has been previously sensitized thereby evoking an eczematous reaction pattern. In this case, the focal dyskeratosis and somewhat atypical phenotypic profile would be more supportive of a drug based trigger.

Click images to begin the slideshow

Slide 1: 55 year-old woman who erupted in dermatitis on abdomen around Lovenox injection site. Dermatitis involves 40% of the body.

Slide 2: he epidermis is mildly acanthotic. There is an inflammatory cell infiltrate in the dermis.

Slide 3: A deeper seated folliculocentric extension of the infiltrate is noted. A foreign body response to follicular derived keratin is noted.

Slide 4: There is spongiosis with scattered necrotic keratinocytes and or streak dyskeratotic cells. A few Langerhans cell rich vesicles are noted. There is a mixed inflammatory cell infiltrate in the dermis which is both interstitial and angiocentric.

Slide 5: There is spongiosis with scattered necrotic keratinocytes and or streak dyskeratotic cells. There is a mixed inflammatory cell infiltrate in the dermis which is both interstitial and angiocentric. The lymphocytes are predominantly small without atypia.

Slide 6: Another image of the superficial dermis which is highly remarkable for a striking pattern of neutrophilic dermolysis whereby seas of neutrophils are associated with disintegration of the connective tissue framework.

Slide 7: Scattered eosinophils are also noted.