RESUMO

There are few case reports of cases of carotid and aortic dissection related to the ergotamine abuse, but the cases that affect the coronary arteries is a very rare coronary. We present a patient of a 48-year-old female with an ST-segment elevation myocardial infarction attributable to chronic ergotamine use. The coronary angiography showed dissection of right coronary artery proximal.

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RESUMO

El ergotismo es un síndrome clínico poco frecuente pero potencialmente letal vinculado a la intoxicación aguda o crónica con el uso de alcaloides del ergot en el tratamiento de la migraña. Se caracteriza por un vasoespasmo severo generalizado que puede generar isquemia periférica o visceral y conducir a disfunción orgánica múltiple y muerte. Existen numerosos fármacos de metabolismo hepático que pueden alterar la metabolización de la ergotamina pudiendo alcanzar concentraciones tóxicas incluso a bajas dosis. Presentamos el caso de un paciente infectado con virus de la inmunodeficiencia humana bajo tratamiento antirretroviral que incluía inhibidores de la proteasa y que se había automedicado con ergotamina. El paciente presentó posteriormente sintomatología sensitivo motora deficitaria de miembros superiores e inferiores, acompañada de elementos de hipoperfusión distal severa. Se solicitó Doppler arterial que evidenció vasoespasmo de ejes arteriales de miembros. Se realizó diagnóstico de ergotismo secundario a la asociación de ergotamina - ritonavir, ingresando a cuidados intensivos. Se inició tratamiento en base a suspensión de ambos fármacos, vasodilatación arterial con nitroprusiato y antiagregación con ácido acetilsalicílico. En relación con este caso se presenta una revisión del mecanismo de toxicidad de la ergotamina, sus interacciones farmacológicas, así como diagnóstico y tratamiento disponibles para esta patología. (AU)

Ergotism is a rare but potentially lethal clinical syndrome linked to acute or chronic poisoning with the use of ergot alkaloids in the treatment of migraine. It is characterized by a severe generalized vasospasm that can generate peripheral or visceral ischemia and lead to multiple organ dysfunction and death. There are numerous drugs of hepatic metabolism that can alter the metabolism of ergotamine and can reach toxic concentrations even at low doses. We present the case of a patient infected with human immunodeficiency virus under antiretroviral treatment that included protease inhibitors and who had self-administered with ergotamine. The patient subsequently presented motor sensory deficit symptoms of upper and lower limbs, accompanied by elements of severe distal hypoperfusion. Arterial Doppler was requested, which showed vasospasm of the arterial axis of the limbs. A diagnosis of ergotism secondary to the ergotamine-ritonavir association was made, entering intensive care. Treatment was started based on suspension of both drugs, arterial vasodilatation with nitroprusside and antiaggregation with acetylsalicylic acid. In relation to this case, we present a review of the ergotamine toxicity mechanism, its pharmacological interactions, as well as the diagnosis and treatment available for this pathology. (AU)

O ergotismo é uma síndrome clínica pouco frequente, porém potencialmente letal vinculado à intoxicação aguda ou crônica pelo uso de alcalóides do Ergot no tratamento da enxaqueca. Caracteriza-se por um vaso espasmo severo generalizado que pode gerar isquemia periférica ou visceral e levar a disfunção orgânica múltipla e morte. Existem múltiplos fármacos de metabolismo hepático que podem alterar a metabolização da ergotamina podendo alcançar concentrações tóxicas inclusive em doses baixas. Apresentamos o caso de um paciente infectado com vírus da imunodeficiência humana recebendo tratamento antirretroviral que incluía inibidores da protease e que se automedicou com ergotamina. O paciente apresentou posteriormente sintomatologia sensitiva motora deficitária de membros superiores e inferiores, acompanhada de elementos de hipoperfusao distal severa. Solicitou-se Doppler arterial que mostrou vaso espasmo dos eixos arteriais de membros. Realizou-se diagnóstico de ergotismo secundário à associação ergotamina - ritonavir, e transferiu-se o paciente a cuidados intensivos. Iniciou-se tratamento com a suspensão de ambos os fármacos, vasodilatação arterial com nitroprussiato e antiagregaçao com ácido acetilsalicílico. Apresenta-se uma revisão do mecanismo de toxicidade da ergotamina, suas interações farmacológicas, seu diagnóstico e os tratamentos disponíveis para esta patologia. (AU)

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RESUMO

A 32-year-old female, was diagnosed in 2004 with a C1 HIV1 infection, using zidovudine/lamivudine 300/150 mg BID and lopinavir/ritonavir 400/100 mg BID, in addition to prophylaxis with trimethoprim-sulfamethoxazole 800/160 mg QD, but no prophylaxis with macrolide antibiotics. The patient presented with a severe headache and was prescribed two capsules of the anti-migraine drug Ormigrein™, which contained ergotamine tartrate 1 mg, caffeine 100 mg, paracetamol 220 mg, hyoscyamine sulfate 87.5 mcg, and atropine sulfate 12.5 mcg. Afterwards she was prescribed one capsule of Ormigrein every 30 minutes for a total of six capsules a day. The patient took the medication as prescribed but developed a pain in her left ankle three days later, which evolved to the need for amputation.

Assuntos

RESUMO

A 32-year-old female, was diagnosed in 2004 with a C1 HIV1 infection, using zidovudine/lamivudine 300/150 mg BID and lopinavir/ritonavir 400/100 mg BID, in addition to prophylaxis with trimethoprim-sulfamethoxazole 800/160 mg QD, but no prophylaxis with macrolide antibiotics. The patient presented with a severe headache and was prescribed two capsules of the anti-migraine drug Ormigrein™, which contained ergotamine tartrate 1 mg, caffeine 100 mg, paracetamol 220 mg, hyoscyamine sulfate 87.5 mcg, and atropine sulfate 12.5 mcg. Afterwards she was prescribed one capsule of Ormigrein every 30 minutes for a total of six capsules a day. The patient took the medication as prescribed but developed a pain in her left ankle three days later, which evolved to the need for amputation.

Mulher de 32 anos infectada pelo HIV 1, vinha utilizando zidovudina/lamivudina 300/150 mg um comprimido duas vezes ao dia e lopinavir/ritonavir 200/50 mg dois comprimidos duas vezes ao dia e profilaxia com sulfametoxazol-trimetoprim 800/160 mg uma vez ao dia, sem profilaxia com macrolídeos. A paciente apresentou enxaqueca severa com prescrição da associação tartarato de ergotamina 1 mg, cafeína 100 mg, paracetamol 220 mg, sulfato de hiosciamina 87,5 mcg, sulfato de atropina 12,5 mcg, dois comprimidos na crise, seguido de um comprimido a cada 30 minutos, com no máximo seis comprimidos ao dia. A paciente ingeriu seis comprimidos em um dia, surgindo uma dor em tornozelo esquerdo três dias depois, que evoluiu para ergotismo e amputação do pé.

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RESUMO

Ergotism is a complication of acute intoxication and/or chronic abuse of ergot derivatives. It expresses itself through a vasomotor syndrome with peripheral vascular disease which frequently involves extremities. We report four cases of HIV-1 infected patients treated with antiretroviral drugs including boosted-protease inhibitors who had self-treated themselves with ergotamine. They developed peripheral vascular disease symptoms and their pulses where diminished or absent in the physical examination. Arterial Doppler confirmed diffused arterial spasm in two of them. Ergotism following ergotamine-protease inhibitors association was diagnosed. Patients were treated through the discontinuity of involved drugs (protease inhibitors and ergotamine), calcium blockers; antithrombotic prophylaxis with enoxaparine, antiaggregant therapy with acetylsalicylic acid, and one of them received pentoxifylline and vasodilator prostaglandins infusion, with amelioration of the symptoms. We discuss the clinical presentation of this drug interaction, difficult to diagnose properly without a strong suspicion of its existence.

Assuntos

RESUMO

El ergotismo es una complicación de la intoxicación aguda y/o el abuso crónico de los derivados del ergot. Se manifiesta por síndrome vasomotor con enfermedad vascular periférica que frecuentemente compromete extremidades. Presentamos cuatro casos de pacientes infectados con el virus de la inmunodeficiencia humana 1 (HIV-1), en tratamiento con antirretrovirales que incluyen inhibidores de la proteasa reforzados con ritonavir, y que habían recibido ergotamina como automedicación. Ellos desarrollaron síntomas de enfermedad vascular periférica y al examen físico sus pulsos estaban disminuidos o ausentes. El Doppler arterial confirmó signos de espasmo arterial difuso en dos de ellos. Se hizo diagnóstico de ergotismo secundario a la asociación de ergotamina-inhibidores de la proteasa. Los pacientes fueron tratados con la discontinuación de las drogas involucradas (inhibidores de la proteasa y ergotamina), bloqueantes cálcicos, profilaxis antitrombótica con enoxaparina, antiagregación con ácido acetil salicílico y uno ellos recibió pentoxifilina e infusión de prostaglandinas vasodilatadoras con mejoría de los síntomas. Discutimos la presentación clínica de esta interacción medicamentosa, difícil de diagnosticar correctamente sin una fuerte sospecha de su existencia.

Ergotism is a complication of acute intoxication and/or chronic abuse of ergot derivatives. It expresses itself through a vasomotor syndrome with peripheral vascular disease which frequently involves extremities. We report four cases of HIV-1 infected patients treated with antiretroviral drugs including boosted-protease inhibitors who had self-treated themselves with ergotamine. They developed peripheral vascular disease symptoms and their pulses where diminished or absent in the physical examination. Arterial Doppler confirmed diffused arterial spasm in two of them. Ergotism following ergotamine-protease inhibitors association was diagnosed. Patients were treated through the discontinuity of involved drugs (protease inhibitors and ergotamine), calcium blockers; antithrombotic prophylaxis with enoxaparine, antiaggregant therapy with acetylsalicylic acid, and one of them received pentoxifylline and vasodilator prostaglandins infusion, with amelioration of the symptoms. We discuss the clinical presentation of this drug interaction, difficult to diagnose properly without a strong suspicion of its existence.

Assuntos

RESUMO

El ergotismo es una complicación de la intoxicación aguda y/o el abuso crónico de los derivados del ergot. Se manifiesta por síndrome vasomotor con enfermedad vascular periférica que frecuentemente compromete extremidades. Presentamos cuatro casos de pacientes infectados con el virus de la inmunodeficiencia humana 1 (HIV-1), en tratamiento con antirretrovirales que incluyen inhibidores de la proteasa reforzados con ritonavir, y que habían recibido ergotamina como automedicación. Ellos desarrollaron síntomas de enfermedad vascular periférica y al examen físico sus pulsos estaban disminuidos o ausentes. El Doppler arterial confirmó signos de espasmo arterial difuso en dos de ellos. Se hizo diagnóstico de ergotismo secundario a la asociación de ergotamina-inhibidores de la proteasa. Los pacientes fueron tratados con la discontinuación de las drogas involucradas (inhibidores de la proteasa y ergotamina), bloqueantes cálcicos, profilaxis antitrombótica con enoxaparina, antiagregación con ácido acetil salicílico y uno ellos recibió pentoxifilina e infusión de prostaglandinas vasodilatadoras con mejoría de los síntomas. Discutimos la presentación clínica de esta interacción medicamentosa, difícil de diagnosticar correctamente sin una fuerte sospecha de su existencia.(AU)

Ergotism is a complication of acute intoxication and/or chronic abuse of ergot derivatives. It expresses itself through a vasomotor syndrome with peripheral vascular disease which frequently involves extremities. We report four cases of HIV-1 infected patients treated with antiretroviral drugs including boosted-protease inhibitors who had self-treated themselves with ergotamine. They developed peripheral vascular disease symptoms and their pulses where diminished or absent in the physical examination. Arterial Doppler confirmed diffused arterial spasm in two of them. Ergotism following ergotamine-protease inhibitors association was diagnosed. Patients were treated through the discontinuity of involved drugs (protease inhibitors and ergotamine), calcium blockers; antithrombotic prophylaxis with enoxaparine, antiaggregant therapy with acetylsalicylic acid, and one of them received pentoxifylline and vasodilator prostaglandins infusion, with amelioration of the symptoms. We discuss the clinical presentation of this drug interaction, difficult to diagnose properly without a strong suspicion of its existence.(AU)

Assuntos

RESUMO

Ergotism is a complication of acute intoxication and/or chronic abuse of ergot derivatives. It expresses itself through a vasomotor syndrome with peripheral vascular disease which frequently involves extremities. We report four cases of HIV-1 infected patients treated with antiretroviral drugs including boosted-protease inhibitors who had self-treated themselves with ergotamine. They developed peripheral vascular disease symptoms and their pulses where diminished or absent in the physical examination. Arterial Doppler confirmed diffused arterial spasm in two of them. Ergotism following ergotamine-protease inhibitors association was diagnosed. Patients were treated through the discontinuity of involved drugs (protease inhibitors and ergotamine), calcium blockers; antithrombotic prophylaxis with enoxaparine, antiaggregant therapy with acetylsalicylic acid, and one of them received pentoxifylline and vasodilator prostaglandins infusion, with amelioration of the symptoms. We discuss the clinical presentation of this drug interaction, difficult to diagnose properly without a strong suspicion of its existence.

Assuntos

RESUMO

Ergotism is a clinical condition known since old times and whose main characteristics are ischemia and even limb gangrene. Some drugs have the capacity of interacting with small amounts of ergotamine or its derivatives producing ergotism as a side effect. This is the case of ritonavir, a widely used anti-HIV drug. Here we present a case of ergotism that developed in an HIV positive 39 year old male under treatment with ritonavir, after taking 1 mg of ergotamine tartrate. His clinical picture, apart from showing the basic manifestations of the disease, was associated with splenic infarction. For this reason, we consider important to advise patients about the potential pharmacological interaction between ergotamines and others common drugs and, in particular, ritonavir in HIV positive patients.

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RESUMO

Introduction: Spontaneous dissection of the iliac artery (SDIA) is an extremely rare clinical manifestation, associated to different etiologies, and it usually shows an ischemia of the involved lower extremity. Clinical case: We report a case of a 48-year-old man, with past medical history of chronicle consumption of ergotamine, which presented left lower limb ischemia, while practicing physical exercise. An emergent contrast-enhanced computed tomography scan showed a spontaneous dissection of the common and the external left iliac artery. An endovascular therapy of the lesion was performed with self-expanding stents, achieving the reconstruction of the lesion, the recovery of the blood flow and of the lower limb ischemia. Conclusions: There are no previous descriptions of the association between ergotamine consumption, sport and this very rare pathology. Endovascular treatment represents a less invasive and, such as in our case report, successful management of the SDIA, and it should be considered among the alternative therapies.

Introducción: La disección espontánea de la arteria ilíaca es un cuadro muy poco frecuente asociado a diferentes etiologías que habitualmente se presenta como isquemia de la extremidad comprometida. Caso clínico: Se reporta el caso de un paciente masculino de 48 años con antecedente de consumo crónico de ergotamina, quien mientras practicaba deporte presenta cuadro de isquemia aguda de la extremidad inferior izquierda. Angio tomografía computada demostró disección espontánea de la arteria ilíaca común y externa izquierda. Se realizó terapia endovascular de la lesión con stents auto expandibles, logrando la reparación de la lesión, el restablecimiento del flujo y la recuperación de la isquemia de la extremidad. Discusión y conclusiones: No existen reportes previos de esta patología poco frecuente, en que se asocie en forma conjunta la práctica de deporte y el uso de ergotamina. Dentro de las alternativas terapéuticas, la reparación endovascular representa una opción menos invasiva y, como en este caso, con óptimos resultados.

Assuntos

RESUMO

El ergotismo es una enfermedad conocida desde la antigüedad, que se caracteriza por isquemia y, en algunos casos, gangrena de las extremidades. Muchas drogas de uso corriente tienen la capacidad de interactuar con los ergotamínicos desarrollando ergotismo como efecto adverso. Un ejemplo de ello es el ritonavir, un inhibidor de la proteasa utilizado en pacientes con el virus de la inmunodeficiencia humana (HIV). Presentamos un caso de ergotismo en un varón de 39 años con infección por HIV en tratamiento con ritonavir que, después de ingerir 1 mg de tartrato de ergotamina, además de presentar manifestaciones clásicas de la enfermedad, desarrolló un infarto esplénico. Por lo tanto, consideramos importante advertir a los pacientes sobre la posible interacción farmacológica entre los ergotamínicos y otras drogas de uso frecuente y, en particular, el ritonavir en pacientes portadores de HIV.

Ergotism is a clinical condition known since old times and whose main characteristics are ischemia and even limb gangrene. Some drugs have the capacity of interacting with small amounts of ergotamine or its derivatives producing ergotism as a side effect. This is the case of ritonavir, a widely used anti-HIV drug. Here we present a case of ergotism that developed in an HIV positive 39 year old male under treatment with ritonavir, after taking 1 mg of ergotamine tartrate. His clinical picture, apart from showing the basic manifestations of the disease, was associated with splenic infarction. For this reason, we consider important to advise patients about the potential pharmacological interaction between ergotamines and others common drugs and, in particular, ritonavir in HIV positive patients.

Assuntos

RESUMO

El ergotismo es una enfermedad conocida desde la antig³edad, que se caracteriza por isquemia y, en algunos casos, gangrena de las extremidades. Muchas drogas de uso corriente tienen la capacidad de interactuar con los ergotamínicos desarrollando ergotismo como efecto adverso. Un ejemplo de ello es el ritonavir, un inhibidor de la proteasa utilizado en pacientes con el virus de la inmunodeficiencia humana (HIV). Presentamos un caso de ergotismo en un varón de 39 años con infección por HIV en tratamiento con ritonavir que, después de ingerir 1 mg de tartrato de ergotamina, además de presentar manifestaciones clásicas de la enfermedad, desarrolló un infarto esplénico. Por lo tanto, consideramos importante advertir a los pacientes sobre la posible interacción farmacológica entre los ergotamínicos y otras drogas de uso frecuente y, en particular, el ritonavir en pacientes portadores de HIV.(AU)

Ergotism is a clinical condition known since old times and whose main characteristics are ischemia and even limb gangrene. Some drugs have the capacity of interacting with small amounts of ergotamine or its derivatives producing ergotism as a side effect. This is the case of ritonavir, a widely used anti-HIV drug. Here we present a case of ergotism that developed in an HIV positive 39 year old male under treatment with ritonavir, after taking 1 mg of ergotamine tartrate. His clinical picture, apart from showing the basic manifestations of the disease, was associated with splenic infarction. For this reason, we consider important to advise patients about the potential pharmacological interaction between ergotamines and others common drugs and, in particular, ritonavir in HIV positive patients.(AU)

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RESUMO

Las interacciones medicamentosas constituyen un factor relevante en lo que a la alteración de la terapéutica se refiere. Dicha importancia debería ser valorada de forma permanente y su detección y prevención deberían constituir dos de los ejes centrales de la actuación del equipo de salud en su ejercicio profesional. La polifarmacia y la automedicación son dos puntos a supervisar. A su vez, la subnotificación al ente regulatorio es una constante que impide la toma de medidas correctivas por parte del mismo. La difusión de alertas y la educación del paciente son medidas fundamentales en este aspecto. Se presentan dos casos que describen el impacto clínico de las interacciones en pacientes ambulatorios.

Drug interactions are a relevant factor as far as the alteration of therapy is concerned. Such an importance should be assessed on an ongoing basis and its detection and prevention should be two of the cornerstones of the health team's performance inpractice. Polypharmacy and self-medication are two points to be monitored. At the same time, the underreporting to the Regulating Entity is a constant that prevents it from taking corrective actions. Warnings dissemination and patient education are key steps at this point. Two cases are presented describing the clinical impact of the interactions on outpatients.

Assuntos

RESUMO

Las interacciones medicamentosas constituyen un factor relevante en lo que a la alteración de la terapéutica se refiere. Dicha importancia debería ser valorada de forma permanente y su detección y prevención deberían constituir dos de los ejes centrales de la actuación del equipo de salud en su ejercicio profesional. La polifarmacia y la automedicación son dos puntos a supervisar. A su vez, la subnotificación al ente regulatorio es una constante que impide la toma de medidas correctivas por parte del mismo. La difusión de alertas y la educación del paciente son medidas fundamentales en este aspecto. Se presentan dos casos que describen el impacto clínico de las interacciones en pacientes ambulatorios.(AU)

Drug interactions are a relevant factor as far as the alteration of therapy is concerned. Such an importance should be assessed on an ongoing basis and its detection and prevention should be two of the cornerstones of the health teams performance inpractice. Polypharmacy and self-medication are two points to be monitored. At the same time, the underreporting to the Regulating Entity is a constant that prevents it from taking corrective actions. Warnings dissemination and patient education are key steps at this point. Two cases are presented describing the clinical impact of the interactions on outpatients.(AU)

Assuntos

RESUMO

Las interacciones medicamentosas constituyen un factor relevante en lo que a la alteración de la terapéutica se refiere. Dicha importancia debería ser valorada de forma permanente y su detección y prevención deberían constituir dos de los ejes centrales de la actuación del equipo de salud en su ejercicio profesional. La polifarmacia y la automedicación son dos puntos a supervisar. A su vez, la subnotificación al ente regulatorio es una constante que impide la toma de medidas correctivas por parte del mismo. La difusión de alertas y la educación del paciente son medidas fundamentales en este aspecto. Se presentan dos casos que describen el impacto clínico de las interacciones en pacientes ambulatorios.(AU)

Drug interactions are a relevant factor as far as the alteration of therapy is concerned. Such an importance should be assessed on an ongoing basis and its detection and prevention should be two of the cornerstones of the health teams performance inpractice. Polypharmacy and self-medication are two points to be monitored. At the same time, the underreporting to the Regulating Entity is a constant that prevents it from taking corrective actions. Warnings dissemination and patient education are key steps at this point. Two cases are presented describing the clinical impact of the interactions on outpatients.(AU)

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RESUMO

Retroperitoneal fibrosis (RPF) associated with chronic use of ergotamine is a very rare disorder. We report a 45-year-old woman who presented with a RPf after using, almost daily for 23 years, ergotamine tartrate for migraine relief. FRP presented as a chronic inflammatory state, anemia, abdominal and lumbosacral pain and a hypogastric mass. A CT-Scan showed a periaortic mass and left hydronephrosis. A percutaneous biopsy was obtained and the patient was subjected to a surgical ureterolysis and tissue resection. The biopsy confirmed the presence of RPf. Due to persistent symptoms and increase in the volume of periaortic tissue, treatment with colchicine 1 mg/day and defazacort 30 mg/day was started, resulting in a rapid disappearance of symptoms, disappearance of inflammation and a significant reduction in the volume of the periaortic tissue. The patient remains in complete remission after 29 months of follow up.

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RESUMO

Retroperitoneal fibrosis (RPF) associated with chronic use of ergotamine is a very rare disorder. We report a 45-year-old woman who presented with a RPf after using, almost daily for 23 years, ergotamine tartrate for migraine relief. FRP presented as a chronicinflammatory state, anemia, abdominal and lumbosacral pain and a hypogastric mass. A CT-Scan showed a periaortic mass and left hydronephrosis. A percutaneous biopsy was obtained and the patient was subjected to a surgical ureterolysis and tissue resection. The biopsy confirmed the presence of RPf. Due to persistent symptoms and increase in the volume of periaortic tissue, treatment with colchicine 1 mg/day and defazacort 30 mg/day was started, resulting in a rapid di-sappearance of symptoms, disappearance ofinflammation and a significant reduction in the volume of the periaortic tissue. The patient remains in complete remission after 29 months of follow up.

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INTRODUCTION: Although ischemic stroke is a well known complication of migraine, cerebral hemorrhage has been uncommonly reported. CASE REPORT: We present the case of a 56-year-old woman with a long history of headache and abuse of ergotamine and antiinflamatory drugs who was admitted for generalized seizures, right hemiparesis and coma. An early brain CT scan showed multiple cortico-subcortical hemorrhages localized amongst others on right frontal, left parietal, and posterior left temporo parietal regions. In the previous two years she had increased the doses on medications containing 1 mg of ergotamine and 500 mg of dipirone consuming two to six tablets a day, and 500 to 1,500 mg of aspirin a day too. Although she exceeded the maximum ergot cumulative doses allowed of 10 mg per week, it cannot be considered a typical nor a pure manifestation of ergotism. When other possible causes of stroke were excluded, the association of migraine with the protracted vasoconstriction of ergotamine, able per se to damage the capillary endothelium, and an altered local hemostasis induced by aspirin remained as the most probable mechanism of brain bleeding. After discharge she had no motor sequelae and she could return to her usual work. A neuropsychological assessment done four months later showed subclinical cognitive deficits depending on an abnormal frontal functioning. CONCLUSION: This life-threatening and potentially disabling complication must stress to physicians about the risks of ergotamine plus aspirin abuse, drawing their efforts to prevent, to recognize and to control the propensity to self medication of some patients with daily headaches.

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