Subsequently, heparin was discontinued, and the patient was switched to oral rivaroxaban (15 mg/d) on day 68 of hospitalization. Necrotic tissue debridement was performed on day 35 of hospitalization (Figure 4), and left side toe amputation and free flap surgery were performed on day 67 of hospitalization (Figure 5). Warfarin was discontinued on the day 22 of hospitalization, and continuous heparin injection was resumed for warfarin-induced skin necrosis, and protein C activity was normalized. Based on these results, the decrease in protein S activity in this patient was attributed to SLE. Protein S activity was normalized with 30 mg of prednisolone (PSL). The activities of protein S and C over time are shown in Figure 3. Therefore, the patient was diagnosed with SLE. Along with lymphopenia, the patient fulfilled 2 clinical and 3 immunologic criteria of the Systemic Lupus International Collaborating Clinics classification: Antinuclear antibody-positive (640-fold, homogeneous) low complement C4 (10 mg/dL reference value, 17-45 mg/dL), C3 (56 mg/dL reference value, 86-160 mg/dL) and CH50 (25 U/mL reference value, 30-45 U/mL) levels and direct Coombs test-positive. When evaluating the cause of decrease in protein S activity in this patient, we observed that she developed pleurisy approximately at the same time as the onset of bilateral deep vein thrombosis of the lower extremities. Figure 2 Skin necrosis observed in the left lower extremity on hospitalization day 19.
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