COUMARIN-INDUCED CEREBRAL DISORDER IN A PATIENT WITH PROTEIN-S DEFICIENCY - PRECURSOR OF COUMARIN-NECROSIS OF THE CNS

Coumarin-induced necrosis of skin and soft tissue is a rare complicati on of oral anticoagulant therapy. Subjects with obesity, deficiency of oestrogen, deficiency of protein C und S have an increased risk for d eveloping this complication. A patient with a history of protein S def iciency is presented who needed anticoagulant therapy for deep vein th rombosis. After 15 mg and 9 mg phenprocoumon on the first and second d ay respectively he developed complex neuropsychiatric symptoms. SPECT revealed a reduced perfusion of the left hemisphere, predominantly of the temporal lobe. EEG showed a focal abnormality in the left frontola teral area. Coumarin was stopped and intravenous heparin (1000 IE/h) w as applied. The neurological disturbances normalised within four days. We feel that this disorder is a precursor of a coumarin-induced CNS n ecrosis. Later successful anticoagulation with phenprocoumon was achie ved by prolonging intravenous heparin and a low daily dose (3 mg) of p henprocoumon.