[Toxic shock-like syndrome after acupuncturation]

A Cumulative Review of the Range and Incidence of Significant Adverse Events Associated with Acupuncture

Objective

To summarise the range and frequency of significant adverse events associated with acupuncture in order to provide evidence on which to base continuing efforts to improve the safety of acupuncture practice.

Methods

Searches were conducted of computerised databases, previous reviews of case reports, population surveys, prospective surveys of acupuncture practice and relevant sections of textbooks for primary and secondary reports to indicate the range of significant adverse events associated with acupuncture. Data from prospective surveys of acupuncture were combined to estimate the incidence of serious adverse events.

Results

A total of 715 adverse events was included. There were 90 primary reports of trauma, and 186 secondary reports; the most common were pneumothorax and injury to the central nervous system. Infection accounted for 204 primary reports and 91 secondary reports. Over 60% of these cases were hepatitis B. The next most common infection was of the external ear, as a complication of auricular acupuncture. The 144 miscellaneous events mainly comprised seizures and drowsiness judged severe enough to cause a traffic hazard. There were 12 primary reports of deaths. According to the evidence from 12 prospective studies which surveyed more than a million treatments, the risk of a serious adverse event with acupuncture is estimated to be 0.05 per 10 000 treatments, and 0.55 per 10 000 individual patients.

Conclusions

The risk of serious events occurring in association with acupuncture is very low, below that of many common medical treatments. The range of adverse events reported is wide and some events, specifically trauma and some episodes of infection, are likely to be avoidable.

Necrotising fasciitis after acupuncture treatment in an immunocompetent patient

A 42-year old male with no significant medical history was admitted to our hospital with a painful, red, swollen right arm and fever. The rash and swelling had started in the cubital fossa. 7 days earlier, needles had been placed exactly at that site during an acupuncture treatment. After deterioration of his condition, surgical exploration of the arm revealed necrotising fasciitis. Although acupuncture is a relatively safe intervention, serious complications do occur. Necrotising fasciitis after acupuncture has been described in immunocompromised patients. To the best of our knowledge this is the first immunocompetent patient with necrotising fasciitis and toxic shock, caused by acupuncture.

The perils of complementary alternative medicine

More than 11,000 articles lauding alternative medicine appear in the PubMed database, but there are only a few articles describing the complications of such care. Two patients suffering from complications of alternative medicine were treated in our hospital: one patient developed necrotizing fasciitis after acupuncture, and the second developed an epidural hematoma after chiropractic manipulation. These complications serve as a clarion call to the Israeli Health Ministry, as well as to health ministries around the world, to include complementary medicine under its inspection and legislative authority.

Systematic review of adverse events following acupuncture: the Japanese literature

CONTEXT

Many Japanese cases of adverse events after acupuncture are not listed in medical databases such as Medline. Therefore, they are not easily accessible to researchers outside Japan.

OBJECTIVE

To complement existing reviews of adverse events after acupuncture in the West and to provide more detailed discussion and analysis.

DATA SOURCES

Literature search using 'Igaku Chuo Zasshi (Japana Centra Revuo Medicina) CD-ROM version' covering the period of 1987-1999.

STUDY SELECTION

Case reports of adverse events, which were suspected to be due to acupuncture treatment, were included. Experimental studies, surveys, and news articles were excluded.

DATA EXTRACTION

Two independent reviewers extracted data from located articles in a pre-defined structured way, and assessed likelihood of causality in each individual case.

DATA SYNTHESIS

89 articles which reported 124 cases were located. The most frequent adverse events were: pneumothorax (25 cases), spinal cord injury (18 cases), acute hepatitis B (11 cases), and localized argyria (10 cases). There were two fatalities from infections. Forty-eight events were caused by needle breakage including 26 cases of intentionally embedded needle and 16 cases of accidental breakage. There were also 10 cases of injury from self-treatment.

CONCLUSION

Although it has already been demonstrated that severe adverse events seem to be uncommon in standard practice, many serious cases of negligence have been found in the present review, suggesting that training system for acupuncturists (including medical doctors) should be improved and that unsupervised self-treatment should be discouraged.

Therapeutic Approaches to Streptococcal Toxic Shock Syndrome

The streptococcal toxic shock syndrome (STSS) is a severe, life-threatening condition characterized by hypotension and multiorgan system dysfunction associated with infection by the group A Streptococcus (GAS) or rarely by streptococci of other Lancefield serogroups. It is associated with a soft tissue infection, such as necrotizing fasciitis, in about half of the cases; the remainder are secondary to a variety of other invasive and noninvasive GAS infections. Although the pathophysiology of STSS is not yet fully understood, there are compelling reasons to believe that the syndrome results at least in part from the action of the streptococcal pyrogenic exotoxins, which act as superantigens. Patients with STSS should be admitted to an intensive care unit for support of cardiovascular, respiratory, and renal function as required. In experimental models of overwhelming GAS infection, clindamycin has greater efficacy than penicillin, and therapy with this agent is recommended. Penicillin, to which GAS are uniformly susceptible, may be used in addition to clindamycin. Limited clinical experience, most of which is anecdotal, suggests marked improvement in some STSS patients after administration of intravenous immunoglobulin. Even in the absence of conclusive data, the potential benefits of intravenous immunoglobulin in this highly lethal disease make its use reasonable in life-threatening cases. Other experimental approaches are also discussed, such as the use of anti-tumor necrosis factor monoclonal antibodies and plasmapheresis.