An atypical case of Purple Glove syndrome: an avoidable adverse event

Rajabally, Hanaa; Nageshwaran, Sathiji; Russell, Sabina

doi:10.1136/bcr.01.2012.5653

Cited by 5 publications

(9 citation statements)

References 9 publications

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“…After review of the associated bibliographies, an additional 26 articles were found [4,13,16,20,21,23,27,29,30,32,33,35,36,38,39,41,42,[45][46][47][48][49][50][51][52][53][54]. In total, 72 patients experienced 82 cases of PGS following IV infusion of phenytoin described from 1984 to 2015.…”

Section: Review Of Reported Casesmentioning

confidence: 99%

“…About one fifth (12/71, 17 %) described development of PGS within 15 min to 2 h and one half (37/71, 52.1 %) within 2 to 12 h after IVadministration of phenytoin. Three (4.2 %) cases reported a time to onset between 12 to 24 h and three (4.2 %) greater than 24 h, with one subject developing symptoms 5 days after the last recorded Numerical data expressed as median (interquartile range) or mean±standard deviation IV intravenous a Primary brain malignancy or brain metastatic lesion b Loading dose 1 g given undiluted as 100 mg IV push every 1 h dose of medication [19,22,44,52]. The median time to symptom onset was 360 min (70-390 min).…”

Section: Review Of Reported Casesmentioning

confidence: 99%

“…The median time to symptom onset was 360 min (70-390 min). A small number of cases described use of various concomitant medications including dexamethasone, mannitol, remifentanil, lidocaine, plasmalyte, benzodiazepines, barbiturates, or neuromuscular blockers [4,18,32,34,37,39,46,47,50,52]. Visible phenytoin precipitation due to medication incompatibilities was reported in one case resulting in full recovery [32].…”

Section: Review Of Reported Casesmentioning

confidence: 99%

“…Two cases of improper phenytoin dilution and resultant drug precipitation described in one pediatric patient led to immediate onset of intense bluish discoloration around the cannula site leading to Bpartial thickness dermal injury^characterized by blistering, mottling, and darkening of the skin [16]. Concurrent administration of phenytoin with benzodiazepines or barbiturates led to PGS with ulcerations at the site of injection and one patient requiring surgical debridement and repair with a skin graft [47,52]. Table 2 displays information on the presentation, diagnosis, and treatment of PGS.…”

Section: Review Of Reported Casesmentioning

confidence: 99%

“…Alterations in appearance including blistering, erythema, or necrosis are more common than deficits in function, such as paralysis or sensory changes, potentially allowing for a more rapid diagnosis [1,6,12,17]. Time to onset of symptoms was generally rapid, consistent with a potentially ischemic pathology, though cases were reported up to 5 days after the last dose of phenytoin [52].…”

Section: Presentationmentioning

confidence: 99%

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

2015

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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, CINA HL, 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 fosphenytoinassociated 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 limbthreatening 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. hemorrhage, and secondary seizure disorder presented with partial left-sided motor seizure progressing to generalized tonic-clonic activity in the emergency department. After treatment with 4 mg of intravenous (IV) loraz...

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Section: Review Of Reported Casesmentioning

confidence: 99%

Section: Review Of Reported Casesmentioning

confidence: 99%

Section: Review Of Reported Casesmentioning

confidence: 99%

Section: Review Of Reported Casesmentioning

confidence: 99%

Section: Presentationmentioning

confidence: 99%

See 3 more Smart Citations

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

2015

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Antiepileptic Drugs

Beal¹

2014

Side Effects of Drugs Annual

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Phenytoin Induced Purple Glove Syndrome: An Effective Management Technique

Mutsago,

Kazzazi,

Ibrahim

et al. 2024

Hosp Pharm

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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.

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An atypical case of Purple Glove syndrome: an avoidable adverse event

Cited by 5 publications

References 9 publications

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

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

Antiepileptic Drugs

Phenytoin Induced Purple Glove Syndrome: An Effective Management Technique

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