Saint Anthony's fire revisited. Vascular problems associated with migraine medication

Cutaneous Pseudovasculitis

Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.

Headache patients in primary care and a tertiary care unit in Zürich, Switzerland

The Headache and Pain Clinic (HPC) is a unit of the Zürich Neurology Department, established in 1966. In the present study demographic features, clinical characteristics and medical management of primary and tertiary care patients were compared in two groups of 181 patients each, seen by general practitioners (GPs) or the HPC, respectively, for primary headaches in 1998. There was a preponderance of women and the socially underprivileged in both samples. Chronic headache was overrepresented in the HPC (44.7%). Loss of work for >2 months was found exclusively in the HPC (9.9%). Of the GP patients, 40% were using triptans and 26.5% in the HPC. One-third of both groups had had complementary and alternative medical treatment. Differences in management strategies reflected differences in headache severity and chronicity. Results indicated that remaining shortcomings of diagnosis and treatment of headache in primary care could be minimized by involving GPs in similar non-commercial studies.

Diagnostic approach to patients with suspected vasculitis

Vasculitis presents several diagnostic challenges. Firstly, patients could present with protean clinical manifestations with a wide spectrum ranging from isolated cutaneous vasculitis to multisystem involvement. Secondly, there are several medical conditions that could mimic the presentation of vasculitis. The range of differential diagnosis is therefore broad. Thirdly, vasculitis could occur as a primary disorder or be secondary to various medical conditions. It becomes important to differentiate them, as treatment of some forms of vasculitis such as those that are secondary to infection or drugs, is different from that of primary vasculitis. Fourthly, there are several different forms of vasculitis. Some are benign and self limiting, while others have the potential to threaten vital organ function and life. It follows that a rational approach is required during evaluation of patients with suspected vasculitis.

Ergotisme chronique : atteinte médullaire et mononeuropathie

INTRODUCTION

Neuropathologic manifestations due to chronic ergotism are rare.

OBSERVATION

We report the case of a 40-year-old patient who presented clinical signs and symptoms of a spinal lesion and also the symptoms of neuropathy involving the right sciatic nerve, more precisely the internal and external popliteal nerves, following ingestion of methysergide. Complete recovery was achieved with calcium blocker treatment.

CONCLUSION

Ergotism should be considered in patients treated by ergot alkaloids presenting an atypical clinical manifestations.

Successful treatment of ergotism with Iloprost--a case report

A 34-year-old woman was hospitalized for severe acute arterial insufficiency of the limbs. Overuse of ergotamine derivative was acknowledged by the patient, who had a long history of migraine headaches. An arteriogram showed diffuse arterial spasm and occlusion of right leg distal arteries. Intravenous infusion of a stable prostacyclin analog (Iloprost) was administered. Rapid and complete improvement of arteriospasm was noted within a few hours, confirmed by a further arteriogram. This appears to be one of the rare case reports of successful limb salvage by use of Iloprost for ergotism.

Acute upper extremity ischemia during concomitant use of ergotamine tartrate and ampicillin

Individual hypersensitivity to the vasoconstrictor effects of ergotamine tartrate has been observed even at doses within recommended limits. Hypersensitivity can be induced by concomitant use with other drugs. The best-documented example of drug-induced hypersensitivity to ergotamine tartrate involves antibiotics of the macrolides class. The mechanism underlying this interaction appears to be interference with metabolism of ergotamine tartrate by the liver. In the present report we describe a case of upper extremity ischemia during concomitant use of ergotamine tartrate and ampicillin. The fact that the effect was not dose-dependent, disappeared when administration of ampicillin was discontinued, and reappeared when administration of ampicillin was resumed suggests that the underlying mechanism in our patient was immunologic. Since immunologic hypersensitivity to the vasoconstrictor effects of ergotamine tartrate is unpredictable, great caution and close surveillance is advisable when ergotamine tartrate is used in association with other drugs.

A role for platelet-derived growth factor in drug-induced chronic ergotism? A case report

Generalized vasoconstriction in chronic ergot poisoning is attributed both to the ergotamine activity on alpha-adrenergic receptors and to its direct action on vascular smooth muscle cells. The authors propose that endothelial wall, chronically damaged by ergot alkaloids, releases platelet-derived growth factor (PDGF), which contributes to vasoconstriction and promotes further arterial obstruction. Their hypothesis is supported by the increased PDGF activity found in plasma of a patient suffering from chronic ergotism.

A randomized, double-blind, comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine

STUDY OBJECTIVE

To evaluate the relative efficacy of ketorolac tromethamine and meperidine hydrochloride in the emergency department treatment of severe migraine.

DESIGN

Prospective, randomized, double-blind trial.

SETTING

University hospital ED.

PARTICIPANTS

Patients presenting to the ED with an isolated diagnosis of common or classic migraine.

INTERVENTIONS

Subjects were randomized to receive a single intramuscular injection of either 30 mg ketorolac or 75 mg meperidine.

MEASUREMENTS AND MAIN RESULTS

Of the 31 patients completing the trial, 15 received ketorolac and 16 received meperidine. The demographic characteristics of both groups were comparable. At one hour, ketorolac was significantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P = .01). Ketorolac also was less effective at reducing nausea, photophobia, and the need for rescue medication (P less than .05). Sustained headache relief was experienced by 44% of the patients treated with meperidine at 12- to 24-hour follow-up, compared with 13% of the patients treated with ketorolac (P = NS). No significant side effects were observed for either group.

CONCLUSION

IM ketorolac tromethamine is less effective than meperidine in the ED treatment of severe migraine.