Rivaroxaban induced leukocytoclastic vasculitis: an uncommon side effect of an emerging anticoagulant in Sri Lanka

Rivaroxaban, a commonly used direct oral anti-coagulant, is often preferred for venous throm-boembolism due to its predictable anticoagulant effect and limited requirement for laboratory monitoring. However, rare adverse effects such as leukocytoclastic vasculitis (LCV) have occasionally been reported. We describe a 42-year-old woman with severe pulmonary hypertension and possible chronic thrombo-embolic pulmonary hyper-tension who developed a progressive petechial rash on both lower limbs two months after initiating rivaroxaban therapy. The clinical presen-tation was not associated with ulceration or bullae and examination revealed signs of right heart failure consistent with her underlying pulmonary hypertension. A skin biopsy confirmed the diag-nosis of LCV, showing perivascular neutrophilic infiltration with focal vessel wall destruction, fibrinoid necrosis and extravasated red blood cells. Rivaroxaban was promptly discontinued, anti-coagulation was switched to warfarin and the skin rash completely resolved following cessation of rivaroxaban. This case highlights the importance of maintaining a high index of suspicion for cutaneous vasculitis in patients on rivaroxaban who develop new skin lesions and underscores the role of timely diagnosis and drug withdrawal in ensuring clinical resolution.