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Letters to the Editor 435 since 1990 have reported the use of terlipressin for the treatment of HRS with good outcomes and low risk of adverse effects. Incidence of secondary ischaemic events in HRS differs depending on series from 5% to 29% (1. 2, 8, 9). Significantly, a recent meta-analysis revealed that no permanent interruption of terlipressin was needed because of intolerance ( I ).Undesirable effects are usually mild and disappear by lowering the dose of the drug. i.e. paleness, acral cyanosis, abdominal pain, diarrhoea, headache and self-limiting cardiac arrhythmias. However, serious ischaemic events, such as skin necrosis involving the extremities, scrotum, penis or abdominal skin have been documented (1-3, 5, 6. 8. 9). Obesity, venous insufficiency and spontaneous bacterial peritonitis have been proposed as possible risk factors for the development of ischaemic cutaneous complications (3, 5).Our patient did not have a medical history of ischaemic disease and, at physical examination, he was not obese and showed no signs of venous insufficiency. Repeated negative ascitic cultures ruled out a spontaneous bacterial peritonitis. The doses of terlipressin administered were low. This case is of clinical importance due to the large area of cutaneous necrosis and its rapid occurrence, without resolution after terlipressin withdrawal.In conclusion, we report here a new case of cutaneous necrosis secondary to terlipressin therapy for management of HRS. Although rare, we must bear in mind the possibility of ischaemic complication of terlipresshi.

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