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Prolonged Transient Hand Ischaemia Secondary to a Penicillin Skin TestDepartment of Orthopaedic and Traumatology, Faculty of Medicine, Inonu University, Malatya, Turkey E-mail: kertem{at}inonu.edu.tr Dear Sir, A 48 year-old man was referred to us with prolonged transient hand ischaemia secondary to a skin test for penicillin allergy carried out 9 hours previously. The patient had experienced pallor and coldness of his hand immediately after the skin test. He had no knowledge of the volume of fluid injected. Nine hours after the injection, he noticed the appearance of a purple discoloration and swelling which started at his wrist and progressed to the tips of fingers. On examination on presentation, there was purple discoloration of the palmar aspect of the right hand, cyanosis of the fingers and delayed capillary refill and coldness of the fingertips compared to the normal side. The hand was also oedematous, painful and swollen. On the distal part of the flexor aspect of his right forearm, well away from the major arteries, there was an erythematous reaction around the injection site. The radial and ulnar pulses were detectable. There was no tenderness at any site of the involved hand on palpation and no increase of pain with passive finger motion, particularly on extension of the fingers. On neuromuscular examination, there was no deficit except for slight weakness of the right hand. The patient gave no history of recent trauma, or of a bleeding diathesis. Blood PO2 was measured from the right and left index fingers and was 97 and 98 mmHg, respectively. Although plain X-ray showed no abnormality, ultrasonography showed hyperechogenicity under the skin when compared with the left arm, although there was no evidence of any loculated fluid collection in the subcutaneous tissues. There was also no difference in arterial and venous Doppler ultrasonography between the two limbs. After medical, dermatological and cardiothoracic consultations, a diagnosis of prolonged transient ischaemia secondary to skin testing for penicillin allergy was made. He was treated with an antiaggregant – Aspirin, a calcium channel blocker –Nifedipine, low-molecular weight heparin – Nadroparin Calcium and pentoxifyllin. He was also instructed to stay in normal room temperature conditions until complete recovery of the disabled hand circulation, to avoid the vasoocclusive effects of cold on the peripheral circulation. At follow-up, 7 days after the injection, cyanosis was still present in all of the digits, as well as erythema of the palm (Fig 1). This appearance had changed little from that on initial presentation. Eighteen days later, the erythema had reduced and was limited to the thumb, index and middle fingers, and the cyanosis was only in the middle and ring fingers. Medical treatment was terminated after 2 months. On examination 11 months after the incident, the only visible defect was pulp atrophy of the middle finger (Fig 2). Sensory and motor testing of the hand and wrist was normal. Grip strength was 6% less than that of the left hand. However, pinch strength to the index and middle fingers was 17% and 15% less than pinch to the equivalent fingers of the left hand, respectively.
Some reactions to penicillin occur between 1 and 72 hours after administration and are IgE mediated. These reactions, termed "accelerated reactions", can manifest as urticaria, angioedema, laryngeal oedema and wheezing. However, urticaria and angioedema can occur at any time after administration of penicillin. Life-threatening reactions occurring beyond 1 hour of penicillin administration are rare (Salkind et al., 2001). Late penicillin hypersensitivity reactions are those that occur after 72 hours from drug administration. These reactions have been classified as Types II, III or IV, depending on the immune mechanism underlying the response. Because none of these reactions are IgE dependent, skin testing is only of value for accelerated reactions and has no role in the assessment of a patient with Types II, III, IV or idiopathic responses to penicillin (Gell and Coombs, 1975; Levine, 1966). Skin testing can be accomplished by the percutaneous route (diluted allergen is pricked or scratched into the skin surface) and by the intradermal route (injection of allergen within the dermal layer). Positive-control skin tests (histamine) and negative-control skin tests (diluent) are essential for correct analysis of skin test reactions. About 15 minutes after the application of allergen to the skin, the test site is checked for a wheal and flare reaction. A positive skin test reaction (characteristically, a wheal 3 mm greater in diameter than the negative control reaction, accompanied by surrounding erythema) shows the existence of mast cellbound IgE specific to the tested allergen (Li, 2002). In this case, we think that the coldness and cyanosis of the right hand was a result of failure in the arterio-venous circulation of the hand at a capillary level. Beginning 9 hour after the injection, this fits well with an accelerated reaction mediated by IgE. This case is presented to illustrate a likely pattern of referral of patients presenting with this problem to hand surgeons.
Journal of Hand Surgery (European Volume), Vol. 32, No. 6,
723-725 (2007)
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