A case of peripheral gangrene and osteomyelitis secondary to terlipressin therapy in advanced liver disease

Abstract

Variceal bleeding and hepatorenal syndrome (HRS) are serious and life-threatening complications of advanced liver disease. Terlipressin is widely used to manage both acute variceal bleeding and HRS due to its potency and long duration of action. The most severe (though rare) adverse event is ischemia. The present report describes the case of a patient with gangrene and osteomyelitis secondary to terlipressin therapy. A 71-year-old male with alcoholic liver cirrhosis (Child-Pugh B) and chronic hepatitis C was admitted due to a drowsy mental status. The patient had several experiences of orthopedic surgery. His creatinine level had gradually elevated to 4.02 mg/dL, and his urine output decreased to 500 mL/24 hr. The patient was diagnosed as having grade III hepatic encephalopathy (HE) and type II HRS. Terlipressin and albumin were administered intravenously to treat the HRS over 11 days. Although he recovered from the HE and HRS, the patient developed peripheral gangrene and osteomyelitis in both feet. His right toes were cured with the aid of rescue therapy, but his left three toes had to be amputated. Peripheral gangrene and osteomyelitis secondary to terlipressin therapy occur only rarely, and there is no specific rescue therapy for these conditions. Thus, attention should be paid to the possibility of ischemia of the skin and bone during or after terlipressin therapy.

Symmetrical peripheral gangrene in critical illness

“…This patient developed severe depletion of natural anticoagulants (antithrombin, 24%; protein C, 20%) in the setting of severe DIC despite not meeting conventional criteria for shock liver. Interestingly, in a previous study reviewing 20 individual case reports of SPG [94], 4 (20%) were noted to have "cirrhosis" [95][96][97][98]. As mentioned earlier, one of the earliest cases of SPG (reported in 1939) occurred in a patient who at autopsy had "cardiac cirrhosis" [5].…”

Terlipressin-induced ischaemic skin necrosis

“…However, there are case reports of terlipressin causing skin necrosis and gangrene (table 1). 4–22 Nineteen articles reporting a total of 25 patients were analysed. Of these patients, 80% were male and the mean age was 58.88±12.36 years.…”

Isolated lower limb gangrene: a caveat of terlipressin therapy

“…Le Moine et al [3] reported the absence of ischaemic complications following high doses of terlipressin (1 mg every 4 hours) administration to a patient with HRS over 2 months. Conversely, gangrenous changes on the toes have been reported to appear on the very first day of terlipressin therapy [4]. Ischaemic events, therefore, are probably independent of the duration of terlipressin therapy.…”