ABSTRACT
OBJECTIVES: Inadvertent intra-arterial injection of flunitrazepam tablets intended for intravenous use by drug abusers has devastating effects. We report here on the clinical outcome of 16 drug abusers developing critical limb ischaemia after flunitrazepam injection. METHODS: Treatment combined immediate analgesia and anticoagulation, long-lasting local thrombolysis and vasodilatation, antibiotic prophylaxis, and physical mobilization. The immediate bolus injection of 5,000 IU heparin was followed by a continuous heparin infusion up to the target partial thromboplastin time. Under arteriographic control local intra-arterial infusion with alternating 4-h cycles of 5 mg recombinant tissue plasminogen activator followed by 5 µg prostaglandinE1 (PGE1) was performed for 24-48 hours. Subsequently, 60 µg PGE1 was applied once daily. RESULTS: Drug abusers, having been injected with 4-30 mg flunitrazepam, were treated 3-72 hours after the accident, with six of them not being treated until after 24 hours. All showed a high tissue ischaemia score. At the time of being discharged from hospital 13 patients had a normal extremity. In one patient, first receiving treatment 72 hours after injection, minor amputation of fingers was necessary. The life of the patient who injected 30 mg flunitrazepam in the leg was saved after hip disarticulation. One patient developed neurological dysfunction in the affected toes. CONCLUSIONS: Intensive treatment after inadvertent intra-arterial drug injection normalized the affected extremity in most drug abusers, even after the late onset of therapy.
Subject(s)
Drug Users , Extremities/blood supply , Flunitrazepam/adverse effects , GABA Modulators/adverse effects , Ischemia/chemically induced , Substance Abuse, Intravenous , Accidents , Adult , Amputation, Surgical , Analgesics/administration & dosage , Anticoagulants/administration & dosage , Combined Modality Therapy , Critical Illness , Drug Administration Schedule , Drug Therapy, Combination , Female , Fibrinolytic Agents/administration & dosage , Flunitrazepam/administration & dosage , GABA Modulators/administration & dosage , Humans , Injections, Intra-Arterial , Ischemia/diagnosis , Ischemia/therapy , Limb Salvage , Male , Physical Therapy Modalities , Retrospective Studies , Time Factors , Time-to-Treatment , Treatment Outcome , Vasodilator Agents/administration & dosage , Young AdultSubject(s)
Paraneoplastic Syndromes , Skin Diseases , Acanthosis Nigricans/diagnosis , Acanthosis Nigricans/pathology , Facial Dermatoses/diagnosis , Facial Dermatoses/pathology , Hand Dermatoses/diagnosis , Hand Dermatoses/pathology , Humans , Hypertrichosis/diagnosis , Hypertrichosis/pathology , Immunosuppression Therapy , Paraneoplastic Syndromes/diagnosis , Paraneoplastic Syndromes/pathology , Pemphigus/diagnosis , Pemphigus/pathology , Skin/pathology , Skin Diseases/diagnosis , Skin Diseases/etiology , Skin Diseases/pathology , Skin Diseases/therapySubject(s)
Paraneoplastic Syndromes , Skin Diseases , Dermatomyositis/diagnosis , Dermatomyositis/therapy , Female , Humans , Keratosis, Seborrheic/diagnosis , Keratosis, Seborrheic/therapy , Male , Paraneoplastic Syndromes/diagnosis , Paraneoplastic Syndromes/therapy , Pemphigoid, Bullous/diagnosis , Pemphigoid, Bullous/therapy , Pruritus/diagnosis , Pruritus/therapy , Pyoderma Gangrenosum/diagnosis , Pyoderma Gangrenosum/therapy , Skin Diseases/diagnosis , Skin Diseases/therapy , Sweet Syndrome/diagnosis , Sweet Syndrome/therapy , SyndromeABSTRACT
Wilson's disease (WD) is an autosomal-recessive inherited disorder of copper metabolism characterized by excessive deposition of copper throughout the body. If medical treatment fails in cases of fulminant hepatic failure and progressive hepatic dysfunction due to advanced cirrhosis, liver transplantation (OLTx) has been demonstrated to be a valuable treatment option. Between December 1993 and December 2002, 225 OLTxs in 198 patients were performed in our institution. In this consecutive series six patients (three females and three males) were liver grafted for WD. The follow-up ranged from 3 to 7 years. All patients are alive with well-functioning grafts at present. The ceruloplasmin levels increased after transplantation and remained normal. The Kayser-Fleischer ring disappeared in all patients, and urinary copper excretion normalized. The neurological manifestations in the two patients with severe neurological symptoms showed after 2 to 5 years a downward tendency; in one the ataxic movements disappeared completely. The psychiatric disorder in one patient disappeared as well the mild neurological symptoms in the patient with CHILD A cirrhosis. These two patients are fully recovered and returned to work. OLTx should be considered as a treatment option in patients with severe progressive neurological deficits even in cases with stable liver function since liver grafting definitely cures the underlying biochemical defect. In such cases an early decision for liver transplantation is justified because neurological deficits may become irreversible.
