Multiple limb compartment syndrome as a manifestation of capillary leak syndrome secondary to metformin and dipeptidyl peptidase IV inhibitor overdose

Abstract

Rationale: Capillary leak syndrome is a condition that increases systemic capillary permeability and causes characteristic manifestations such as recurrent hypovolemia, systemic edema, and hemoconcentration. Acute limb compartment syndrome is a possible complication of severe capillary leak syndrome. However, timely diagnosis and prompt treatment are challenging because of atypical presentation. Patient concerns: An 18-year-old woman with a history of clinical depression was admitted to our intensive care unit (ICU) because of metformin and vildagliptin overdose. She developed marked vasodilatory shock with recurrent severe hypovolemia and disseminated intravascular coagulation. After urgent hemodialysis and plasma exchange, she started to stabilize hemodynamically. However, her limbs became stone-hard with massive edema. Her serum creatinine kinase level increased to an extremely high level. Diagnosis: Extremities were distended, and her skin developed pallor with blistering. Intramuscular pressure in both forearms and lower legs was significantly elevated. Interventions: Decompressive fasciotomy was performed. Hemodialysis was continued because of rhabdomyolyses-induced acute kidney injury. Outcomes: The patient was finally able to walk by herself at the time of hospital discharge on day 109. Lessons: The possibility of acute compartment syndrome should be considered in patients with marked capillary leakage, especially after aggressive fluid resuscitation. It is important to be aware of the compartment syndrome in an ICU setting because communication barriers often mask typical symptoms and make diagnosis difficult.

Therapeutic Plasma Exchange in Severe Rhabdomyolysis: A Case-Control Study

“…Various modalities were used for myoglobin clearance, with the most common being plasmapheresis/therapeutic plasma exchange (nine studies), coupled plasma filtration-absorption (1 study, n=4; Pezzi et al), high flux dialyzer (1 study, n=6; Sorrenti), super high flux membrane (n=1; Naka), and the Cytosorb system, which is a hemoadsorption cartridge added to the hemodialysis circuit (three studies, n=3) [7][8][9][10][11][12][13][14][15][16][17]. On the other hand, several case reports and case series published during this time did not use any modality for myoglobin clearance and used supportive care and other treatments [18][19][20][21][22][23][24][25][26][27][28].…”

Severe edema and blood blisters of the lower extremities caused by sitagliptin, a dipeptidyl peptidase‐4 inhibitor

“…First, adverse drug events should be considered for skin rashes and edema of uncertain cause. Although some reports have been presented in relation to DPP‐4i‐associated bullous pemphigoid 1 or edema, 2 none present a case with severe blood blisters and edema. The mechanism of blister formation induced by DPP‐4i has not been sufficiently clarified.…”

Atraumatic Bilateral Acute Compartment Syndrome of the Lower Legs: A Review of the Literature

“…Four cases underwent fasciotomy in one or more thighs as well as both lower legs [ 12 , 15 - 17 ]. Two other patients required fasciotomy of both forearms [ 18 , 19 ].…”