Phenytoin Induced Purple Glove Syndrome: An Effective Management Technique.

Background: Purple glove syndrome (PGS) is a rare condition characterized by limb edema, discoloration, and pain associated with intravenous and oral phenytoin administration. The pathophysiology is poorly understood, and there is no established treatment. Simple cases have previously been managed with hyaluronidase subcutaneous injections, with more severe cases resulting in compartment syndrome, debridement, or even amputation. Methods/Results: In this case report, a 2-year-old boy with status epilepticus developed PGS after receiving intravenous phenytoin via a cannula on the dorsum of the right hand. The patient was successfully managed by locally infiltrating subcutaneous hyaluronidase diffusely to the affected area, titrating its dose to effect, rather than aiming to adhere to any specific dosing limitation. The child was reviewed daily by the Plastic Surgery team until being discharged, and focal lesions began to demarcate after 48 hours, with epidermal loss but no deeper trauma. The epidermis peeled within one month, with healthy underlying skin found underlying when followed up in clinic. Conclusions: This case illustrates that subcutaneous administration of hyaluronidase and titrating to effect provides an effective and safe treatment for treating distal cases of early PGS in children.

Purple Glove Syndrome: Recognizing a Rare Complication of Intravenous Phenytoin.

An uncommon but serious adverse drug reaction after phenytoin administration is known as purple glove syndrome (PGS). Initial presentation is characterized by pain, skin discoloration, and edema, that can progress to necrosis. The pathophysiology remains uncertain; however, multiple mechanisms have been reported including extravasation. We describe a case of a 61-year-old patient who was brought to the hospital with altered mental status due to status epilepticus. The patient received multiple doses of lorazepam; eventually was started on levetiracetam and valproate, including loading doses. The seizures were poorly controlled despite treatment, and intravenous (IV) phenytoin was added. The next day, bluish discoloration and swelling to bilateral upper distal extremities were noted on physical examination. Consequently, IV phenytoin was discontinued immediately due to high suspicion of PGS. Skin discoloration and edema gradually improved after one week, confirming a case of mild PGS.

Fosphenytoin-induced purple glove syndrome: A case report.

BACKGROUND: Purple glove syndrome (PGS) is a poorly understood severe adverse drug reaction that is typically associated with intravenous phenytoin administration. Although fosphenytoin is thought to circumvent this risk of PGS, we reveal a rare case of PGS in a patient treated with fosphenytoin therapy. CASE SUMMARY: A 71-year-old male with history of epilepsy was admitted for seizures and traumatic brain injury and intravenous fosphenytoin and levetiracetam were initiated. The patient continued to have seizure activity on continuous electroencephalography for which fosphenytoin dosing was increased with subsequent seizure control. Serum phenytoin levels became elevated with a total level reaching as high as 25.8ug/mL. Three days into fosphenytoin therapy he developed PGS in both hands. Causation was assessed with the Naranjo adverse drug reaction algorithm that suggested fosphenytoin was probably the cause of PGS. Ten days after discontinuing the fosphenytoin and administering a 7-day course of methylprednisolone, the purple glove syndrome completely resolved. CONCLUSION: Early recognition and emergent management of PGS are key for optimal recovery. Although fosphenytoin has a significantly reduced risk of associated PGS compared to phenyotin, increased awareness for fosphenytoin-induce PGS can accelerate intervention and minimize morbidity of this rare yet detrimental adverse reaction.

Warfarin and phenytoin drug interaction with possible purple glove syndrome.

Though the impact of phenytoin on warfarin has been reported to potentiate the anticoagulant effect or interact in a biphasic manner, the effect of phenytoin on warfarin appears to be unpredictable and dependent upon multiple factors. Additionally, purple glove syndrome has rarely been reported secondary to therapeutic doses of oral phenytoin. We report on the case of a patient who experienced international normalized ratio (INR) fluctuations upon initiation of warfarin and phenytoin concurrently and who subsequently required discontinuation of therapeutic-dose phenytoin secondary to possible purple glove syndrome.

An anaesthesiologist's encounter with purple glove syndrome.

Purple glove syndrome (PGS) is a devastating complication of intravenous (IV) phenytoin administration. Anaesthetic management during the amputation of the limb for such patients is very challenging due to limited clinical experience. A 65-year-old woman developed PGS of left upper extremity after IV administration of phenytoin following generalised tonic-clonic seizures. The condition progressed rapidly leading to gangrene of left hand extending to the mid arm. Amputation was carried out under general anaesthesia with a supraglottic airway device. We discuss the prevention and alternate managements in PGS, which is a rare clinical entity with limited data in the literature.

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

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, CINAHL, 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 fosphenytoin-associated 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 limb-threatening 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.

Purple Glove Syndrome Caused by Intravenous Phenytoin Injection / 대한피부과학회지

Purple glove syndrome (PGS) is a rare complication of intravenous phenytoin use that is poorly understood and potentially serious. The characteristic features of PGS are pain, edema, and discoloration at the injection site that spreads to the distal limbs. Diagnosis of PGS can be made from clinical presentation, and treatment is usually restricted to conservative therapy. A 7-year-old girl was treated with phenytoin for epilepsy and was referred to our department for violaceous color change and edema on intravenous injection site of the left hand. It was consistent with PGS, and to our knowledge, it is first report in Korea.

A Case of Purple Glove Syndrome

Purple glove syndrome is a complication of the intravenous infusion of phenytoin. It is characterized by progressive distal edema, discoloration and pain. The mechanism of purple glove syndrome is poorly understood, but the chemical properties of intravenous phenytoin and the extravasation of that are possible causes. We present a woman with purple glove syndrome, whose symptoms were subsided gradually with conservative management.