Continuous subcutaneous apomorphine infusion is indicated for use in Parkinson's disease when motor fluctuations occur despite oral and transdermal optimization of the treatment. 1 Side effects are frequent, with the most prevalent being those related to local intolerance, which are responsible for up to 10% of discontinuations. 2, 3 We present the case of a patient who, despite using all the usual techniques to prevent and treat subcutaneous apomorphineinfusion related nodules, continued to present nodules after each daily apomorphine infusion. The nodules remained for several weeks and finally reduced the area of healthy skin suitable for new injections.The patient's own research led him to find a new way to prevent the appearance of nodules with complete success. This report could be a lead for new trials with patients close to abandoning the treatment for this reason. Case ReportWe present a 60-year-old male veterinarian who suffered from advanced Parkinson's disease with motor fluctuations despite several attempts to optimize his oral treatment. After assessing the different options for treatment, continuous subcutaneous apomorphine was chosen.The efficacy was excellent, and he experienced a reduction of his off time with an increased on time without troublesome dyskinesia.Subcutaneous nodules developed after his first injection and after every daily administration of apomorphine (Fig. 1). A nodule biopsy showed panniculitis with lipophagic fat necrosis and low neutrophilic inflammatory infiltrates.The patient followed all the usual recommendations to prevent subcutaneous nodules, such as rotating the injection site, using Teflon needles (Neria soft 90; Unomedical. A ConvaTec Company, Reading, UK) and took precautions with respect to hygiene and the technique employed to insert the needle at a suitable angle.Furthermore, he complied with instructions to treat the nodules by massaging the infusion site with his hands and a spiky massage ball, using silicone gel dressings, applying a topical corticosteroid (clobetasol propionate 0.5 mg/g) to the skin around the injection area after removing the needle, and using low-frequency 3 MHz and 5 MHz ultrasound therapy. 4,5 Nevertheless, all of these efforts proved unsuccessful. The patient's skin was extensively damaged, and he considered discontinuing treatment.The patient's experience as a trained veterinarian led him to explore new methods of making the corticosteroids reach the nodules when the topical treatment proved ineffective. First, he diluted different types of corticosteroids with a low volume of saline serum and apomorphine in different test tubes, and he noted that all of them precipitated to some degree. He found that dexamethasone 21-isonicotinate (Deyanil Retard-Fatro; Fatro Iberica, Barcelona, Spain), a corticosteroid used exclusively in animals, mixed with apomorphine and a saline serum did not precipitate.As this drug was not approved for use in humans, the patient attempted to reproduce the same results with an injectable formulation of dexamethas...
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