Acute
bilateral arterial occlusion in a young woman with no source of embolus
(Portuguese
PDF version)
Coordinated
by Dr. João Luiz Sandri
João
Luiz Sandri1, Giuliano de Almeida Sandri2
1
Assistant Professor of Clinical Surgery, Department of Surgery, School
of Medicine, Santa Casa de Misericórdia de Vitória.
2 Medical Student, Universidade Federal do Espírito
Santo.
J
Vasc Br 2003;2(1):83-84
Part
II - DIAGNOSIS
Ergotism:
a rare cause of lower limb ischemia
The patient
reported that she suffers from migraine and that she had been taking
high doses of ergotamine tartrate (Ormigrein®) in the last few days.
After the diagnosis of ergotism, the treatment consisted of anesthetic
block (already used for pain relief); papaverine (an intraarterial injection
applied to each extremity); total heparin therapy after the removal
of needles for angiography; hydration; and pentoxifylline (400 mg tid).
After 24 hours of therapy, the situation was reversed and the patient
had no pain, although she showed edema on the feet and toes, with mild
tingling, and her pulses were all palpable. After one week, a flow duplex
scanning of the lower limb revealed normal arteries.
Ergot is produced by the fungus Claviceps purpurea, which grows on rye
and other cereal crops. The active components of the drug are alkaloids
derived from lysergic acid. The side effects may be divided into three
categories: (1) neurological - headache, vertigo, psychosis, seizure
and agitation; (2) gastrointestinal - diarrhea, nausea, vomiting and
abdominal colic; and (3) vascular.1,2
The vascular effects of ergot are related to intense and direct vasoconstriction
that predominates in small doses and probably result from the direct
stimulation of alpha receptors on the vessel walls. Aside from these
effects, lesion to the capillary endothelium and hyaline degeneration
of vessel walls are usually found. These effects, albeit observed in
smaller arteries at the extremities, also occur in visceral, coronary,
carotid and ophthalmic arteries.3
The diagnosis of ergotism-induced ischemia is based upon the patient's
clinical history, on physical examination findings and on angiographic
aspects. The presence of lower limb ischemia, especially bilateral and
symmetric, arouses suspicion of ergot-induced vasospasm. The angiographic
findings of arterial spasm, especially bilateral and symmetric, may
be segmental with long and smooth areas of vascular stricture. Spasms
often begin at the superficial femoral artery, suggesting the diagnosis
of ergot-induced vasospasm.3,4
In the case reported herein, the patient was questioned about the use
of drugs only after this type of spasm was detected, thus confirming
the diagnosis, as reported in several other cases in the literature.
The treatment is still empirical, but with the immediate discontinuation
of ergotamine and other vasoactive drugs. The treatment includes the
use of plasma expanders, with good hydration, and systemic heparin therapy,
anesthetic blocks (prior to heparin therapy), vasodilators (nitroglycerine,
papaverine) and calcium channel blockers.5
In more dramatic cases, intraluminal dilation was used to treat vasospasm.6,7
In our setting, Yoshida8 has recommended
the administration of sodium nitroprusside in the dose of 0.5 to 3.0
µg/kg/min, until the situation is clinically normal, which could
take from one to 46 hours, according to the literature.
Although ergotism is rare, clinicians and vascular surgeons should include
this disease in their differential diagnosis in patients with acute
lower limb ischemia, especially those with history of migraine.
REFERENCES
1.
Kempczinzki RF, Buckley CJ, Darling C. Vascular insufficiency secondary
to ergotism. Surgery 1979;79(5):597-600.
2.
Sanders-Bush E, Mayer SE. 5-hydroxytriptamine (serotonin): receptor
agonists and antagonists. In: Hardman JG, Limbird LE, Gilman AG, editors.
Goodman e Gilman's The Pharmacological Basis of Therapeutics. New
York: Mac Graw-Hill; 2001. p. 269-290.
3.
Wells KE, Steed DL, Zajko AB, Webster MW: Recognition and treatment
of arterial insufficiency from cafergot. J Vasc Surg 1986;4:8-15.
4.
Tay JC, Chee YC. Ergotism and vascular insufficiency: a case report
and review of literature. Ann Acd Med Singapore 1998;27:285-8.
5.
Karam B, Farah E, Ashoush R, Jebara V, Ghayad E. Ergotism precipitated
by Erythromycin: a rare Case of Vasospasm. Eur J Vasc Endovasc Surg
2000;19:96-8.
6.
Baader W, Herman W, Johansen K. Le Feu de Saint Antoine: guérison
du vasospasme périphérique dû à lérgoptamine
par la dilatation artérielle hydrostatique. Ann Chir Vasc 1990;4:597-9.
7.
Shifrin E, Perel A, Olschwang D, Diamant Y, Cotev S. Reversal of ergotamine
induced arteriospasm by mechanical intra-arterial dilatation. Lancet
1980;13:1278.
8.
Yoshida B W. Ergotismo. In: Maffei FHA, Lastória S, Yoshida
WB, Rollo HR. Doenças Vasculares Periféricas. 3ª
ed. Medsi: Rio de Janeiro; 2002.
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