Upper limb artery segmental occlusions due to chronic use of ergotamine combined with itraconazole, treated by thrombolysis

Thrombosis Journal

Stefano M Giulini²  Roberto Maroldi¹  Franco Nodari²  Roberto Maffeis²  Federico Gheza²  Giuseppe Battaglia¹  Stefano Bonardelli²  Edoardo Cervi² 

[1] Radiologic clinic, University of Brescia, 25123, Brescia, Italy;Surgical Clinic, University of Brescia, 25123, Brescia, Italy

关键词: Itraconazole;    upper limb ischemia;    fibrinolysis;    Ergotamine;   

Others  :  839025
DOI  :  10.1186/1477-9560-9-13

 received in 2011-01-28, accepted in 2011-08-30,  发布年份 2011

【 摘 要 】

Background

The ergotamine tartrate associated with certain categories of drugs can lead to critical ischemia of the extremities. Discontinuation of taking ergotamine is usually sufficient for the total regression of ischemia, but in some cases it could be necessary thrombolytic and anticoagulant therapy to avoid amputation.

Case report

A woman of 62 years presented with a severe pain left forearm appeared 10 days ago, with a worsening trend. The same symptoms appeared after 5 days also in the right forearm. Physical examination showed the right arm slightly hypothermic, with radial reduced pulse in presence of reduced sensitivity. The left arm was frankly hypothermic, pulse less on radial and with an ulnar humeral reduced pulse, associated to a decreased sensitivity and motility.

Clinical history shows a chronic headache for which the patient took a daily basis for years Cafergot suppository (equivalent to 3.2 mg of ergotamine).

From about ten days had begun therapy with itraconazole for vaginal candidiasis. The Color-Doppler ultrasound shown arterial thrombosis of the upper limbs (humeral and radial bilateral), with minimal residual flow to the right and no signal on the humeral and radial left artery.

Results

Angiography revealed progressive reduction in size of the axillary artery and right humeral artery stenosis with right segmental occlusions and multiple hypertrophic collateral circulations at the elbow joint. At the level of the right forearm was recognizable only the radial artery, decreased in size. Does not recognize the ulnar, interosseous artery was thin. To the left showed progressive reduction in size of the distal subclavian and humeral artery, determined by multiple segmental steno-occlusion with collateral vessels serving only a thin hypotrophic interosseous artery.

Arteriographic findings were compatible with systemic drug-induced disease. The immediate implementation of thrombolysis, continued for 26 hours, with heparin in continuous intravenous infusion and subsequent anticoagulant therapy allowed the gradual disappearance of the symptoms with the reappearance of peripheral pulses.

Conclusion

Angiography showed regression of vasospasm and the resumption of flow in distal vessels. The patient had regained sensitivity and motility in the upper limbs and bilaterally radial and ulnar were present.

【 授权许可】

   
2011 Cervi et al; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Thrush Q: Does work ergotamine for migraine? In Magement in the Dilemmas of the neurological patient. Edited by Warlow C, Garfield J. Edinburgh: Churchill Livingstone; 1984:106-13.
• [2]Merhoff GM, Porter JM: Ergot intoxication: historical review and description of unusual clinical Manifestations. Ann Surg 1974, 280:773-9.
• [3]Wilkinson M: Ergotamine Headaches. In Migraine and Beta-Blockkade. Edited by Carroll JD, Pfaffenrath V, Sjaastad O. Uddevalla: Bohuslaeningens Boktryckeri; 1985:176-179.
• [4]Stoll : Recent Investigation of ergot alkaloids. Chem Rev 1950, 47:197.
• [5]V-Wing Hurula, My llyla V, Hokkanen E: Ergotamine abuse: results of ergotamine discontinuation, with special reference to the plasma concentrations. Cephalalgia 1982, 2:189-195.
• [6]Young JR, Huphries AW: Severe arteriospasm after use of erfotamine tartrate suppositories. Report of a case. JAMA 1961, 175:107-11.
• [7]Felix RH, Carroll JD: Upper limb ischaemia due to ergotamine tartrate. Practitioners 1970, 205:71-2.
• [8]McKiernan TL, Bock K, Leya F, Grassman E, Lewis B, Johnson SA, Scanlon PJ: Ergot induced peripheral vascular insufficiency, non-interventional treatment. Cathet Cardiovasc Diagn 1994, 31:211-4.
• [9]Martinet O, Vuilleumier H, Fournier D, Jayet A, Genton A, Chapuis G: Value of duplex ultrasound in diagnosis of ergotism of the legs. Swiss Surg 1995, 6:311-3.
• [10]D'Amore MJ, Borge MA, Messersmith RN: Limb threatening lower-extremity ischemia succesfully Treated with intra-arterial infusions case report. Angiology 1999, 50:233-7.
• [11]Bongard O, Bounameaux H: Severe iatrogenic ergotism: incidence and clinical importance. Vasa 1991, 20:153-6.
• [12]Carliner N, Denune DP, Finch CS Jr, Goldberg LI: Sodium nitroprusside treatment of ergotamine-induced peripheral ischemia. JAMA 1974, 227:308-9.
• [13]Ghali R, De Lean J, Douville Y, Noel HP, Labbe R: Erythromycin-associated ergotamine intoxication: arteriographic and electrophysiologic analysis of a rare cause secere of ischemia of the Lower Extremities and Associated ischemic neuropathy. Vasco Ann Surg 1993, 7:291-296-9.
• [14]Liaudet L, Buclin T, Jaccard C, Eckert P: Drug points: severe ergotism Associated with Interaction Between ritonavir and ergotamine. BMJ 1999, 318:771.
• [15]Baldwin ZK, Ceraldi CC: Ergotism associated with HIV antiviral protease inhibitor therapy. J Vasc Surg 2003, 37:676-8.