Purple glove syndrome following intravenous phenytoin administration

Chokshi, Reena V.; Openshaw, John J.; Mehta, Nehal N.; Mohler, Emile R.

doi:10.1177/1358863x07076551

Cited by 21 publications

(16 citation statements)

References 11 publications

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“…Nonetheless, 39.4 % of cases occurred with an 18 gauge or larger catheter and 12.5 and 8.9 % with IV catheters in the forearm and antecubital fossa, respectively, suggesting that no size or location is exempt from occurrence. While it has been hypothesized that comorbid peripheral arterial disease may predispose patients to PGS, we were only able to document one case in which the subject had a known history [37]. This is limited, however, by the lack of consistent documentation of patient comorbidities among the reviewed studies as well as a likely under-appreciation of the prevalence of this disease among patients.…”

Section: Risk Factorsmentioning

confidence: 97%

“…Over one half (22/43, 64.1 %) had a history of epilepsy, though patient comorbidities were described in only 43 of 82 cases. One patient was noted to have a known history of peripheral arterial disease [37].…”

Section: Review Of Reported Casesmentioning

confidence: 99%

“…The median time to symptom onset was 360 min (70-390 min). A small number of cases described use of various concomitant medications including dexamethasone, mannitol, remifentanil, lidocaine, plasmalyte, benzodiazepines, barbiturates, or neuromuscular blockers [4,18,32,34,37,39,46,47,50,52]. Visible phenytoin precipitation due to medication incompatibilities was reported in one case resulting in full recovery [32].…”

Section: Review Of Reported Casesmentioning

confidence: 99%

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Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

2015

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The aim of our study was to identify all previously reported cases of phenytoin-or fosphenytoin-associated purple glove syndrome (PGS) and summarize the most current understanding of the pathophysiology, clinical presentation, diagnosis, and treatment of the disease. We searched the English language references from MEDLINE, EMBASE, CINA HL, TOXNET, and gray literature that featured one or more case descriptions of phenytoin-or fosphenytoin-associated PGS after administration and provided information on the clinical setting of the event and associated outcome(s). Descriptive statistics were employed to summarize relevant facts about the cases. We identified 82 unique cases of parenteral phenytoin-associated PGS and 5 cases of fosphenytoinassociated PGS that were published from 1984 to 2015. Additionally, we found two cases of PGS associated with oral formulation of phenytoin published from 1999 to 2015. The spectrum of tissue injury ranged from mild local cutaneous reactions around the infusion site to frank limb ischemia. Just over a half of cases reported symptoms after one dose of IV phenytoin. Pathologic findings included evidence for microvascular thrombosis and possible microvascular or subclinical extravasation as a contributing mechanism. Dopper ultrasound and conventional angiography were used in some patients to identify arterial or venous thrombosis. Various treatments were documented including the use of supportive care such as limb elevation and heat or cold application, utilization of systemic antibiotics, anticoagulants, or vasodilators, and local infiltration of hyaluronidase, heparin, or other compounds. In a small number of patients, invasive interventions such as regional anesthesia, thrombectomy, fasciotomy, and debridement were described. Time to resolution varied from days to weeks. Resolution of PGS without deficits was documented in the majority of cases. Skin changes followed by sensory and motor deficits were described in 16, 6, and 5 cases, respectively. Four patients underwent skin grafting and eight patients required limb amputation. Death as a result of PGS was documented in two patients. PGS associated with oral and injectable phenytoin or parenteral fosphenytoin has been documented in the literature and sometimes includes significant vascular thrombosis and potentially limbthreatening ischemia. Avoidance of small hand veins, adherence to recommended IV administration guidelines and monitoring of the infusion site for reactions should be considered to decrease the morbidity of IV phenytoin or fosphenytoin use. Patients with PGS and evidence of decreased distal perfusion should undergo prompt vascular imaging and potential intervention to avoid ischemic sequelae. Alternative anticonvulsant drugs should be considered in patients at risk for PGS when possible. hemorrhage, and secondary seizure disorder presented with partial left-sided motor seizure progressing to generalized tonic-clonic activity in the emergency department. After treatment with 4 mg of intravenous (IV) loraz...

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Section: Risk Factorsmentioning

confidence: 97%

Section: Review Of Reported Casesmentioning

confidence: 99%

Section: Review Of Reported Casesmentioning

confidence: 99%

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Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

2015

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“…Die intraven ö se Gabe wird zur Behandlung von Grandmal-Anf ä llen im Rahmen eines Status epilepticus und zur Anfallsprophylaxe bei neurochirurgischen Eingriff en empfohlen. Eine ernsthafte Komplikation der peripheren ven ö sen Gabe oder der Ü berdosierung der oralen Gabe (bislang erst eine Fallbeschreibung) [16] von Phenytoin ist das Purple Glove Syndrom [5] . Neben vor ü bergehenden Verf ä rbungen, Ö demen, Bewegungseinschr ä nkungen und Schmerzen kann es zu Nekrosen, Kompartmentsyndrom, Superinfektionen …”

Section: Fallbericht and Anamneseunclassified

Purple Glove Syndrom nach peripherer venöser Phenytoin Gabe – Ein Fallbericht

Warnecke¹,

Raute-Kreinsen²,

Schirmer³

et al. 2009

Handchir Mikrochir plast Chir

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The purple glove syndrome (PGS) is a soft tissue injury after peripheral intravenous phenytoin administration or oral overdosage. The incidence of PGS is described with 0-6%. Typical symptoms are purple discoloration, oedema, pain, and a decrease of range of motion. In severe cases PGS may lead to abscess, skin loss and compartment syndrome. The established treatment of PGS is immediate interruption of phenytoin injections, splinting, elevation, and close observation. In cases of severe complications (e. g., compartment syndrome), surgical intervention is necessary. The case of a 40-year-old female patient is reported who was transferred to our department 4 days after intravenous phenytoin administration and who underwent successful surgical revision.

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“…During the first stage, which occurs within 2 to 12 hours after infusion of IV phenytoin, a dark purple-bluish discoloration of the skin appears around the site of IV phenytoin infusion. 2 In the second stage, which occurs in the next 12 to 16 hours, edema develops and there is progression of the dark purple-bluish discoloration around the skin Purple Glove Syndrome surrounding the infusion site. 1,4 During the final stages of PGS, healing occurs with resolution of edema and receding of skin tissue discoloration.…”

mentioning

confidence: 99%

Phenytoin-Induced Purple Glove Syndrome: A Case Report and Review of the Literature

et al. 2015

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Objective: To present a case report and literature review of phenytoin-induced purple glove syndrome (PGS). Case summary: A 54-year-old African American male presented to our hospital's emergency department (ED) following a seizure episode, cardiac arrest, and loss of consciousness. On arrival to the ED, the patient's total phenytoin level was subtherapeutic at 4.1 mcg/mL and his corrected total phenytoin level was subtherapeutic at 5.1 mcg/mL. In the ED, the patient received a loading dose of intravenous (IV) phenytoin 1,000 mg once via the left cephalic vein, at a rate of 50 mg/min, and was admitted to the medicine service. A day following IV phenytoin administration, a nurse noticed an IV fluid infiltration on the skin tissue around the left cephalic vein. The area appeared dark blue and purple in color, swollen, erythematous, and warm to touch. An ultrasound of the left upper extremity was performed and revealed subcutaneous fluid collection without evidence of thrombosis. Discussion: The Naranjo Adverse Drug Reaction Probability Scale assigned a score of 7, indicating phenytoin as the probable cause of purple glove syndrome (PGS). The patient's PGS was managed with a combination of dry dressing material, left forearm elevation, collagenase topical cream, 0.1% IV bupivacaine, and IV fentanyl. The patient's injury was resolving at the time of discharge to a rehabilitation facility. Conclusion: PGS is a rare complication of IV phenytoin therapy. The risk of PGS for this patient may have been abated by decreasing the phenytoin infusion rate from 50 mg/min to less than 25 mg/min.

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Purple glove syndrome following intravenous phenytoin administration

Cited by 21 publications

References 11 publications

Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

Purple Glove Syndrom nach peripherer venöser Phenytoin Gabe – Ein Fallbericht

Phenytoin-Induced Purple Glove Syndrome: A Case Report and Review of the Literature

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