Introduction

Ergotism is a rare complication of acute intoxication or chronic ingestion of ergotamine derivatives, regardless of the dose [1]. Ergotamine is frequently used for the treatment of acute and chronic migraine [2]. This is due to its ability to cause sustained vasoconstriction, especially at the brain level. Over-medication ergotism is extremely rare and requires high doses over a prolonged period. However, since the introduction of antiretroviral for the treatment of HIV, ergotism symptoms have been described related to the concomitant use of these drugs that inhibit the hepatic metabolism of ergotamine through the inhibition of cytochrome P450 [3,4]. The most common form of presentation of ergotism is peripheral arterial ischemia. Clinical picture is characterized by generalized arterial vasospasm, predominantly in the lower limbs, causing an acute vascular event. These patients are usually referred to groups of vascular surgeons or specialists in endovascular intervention for evaluation and treatment. Among the multiple therapeutic modalities available, the administration of arterial vasodilators constitutes a central element for the treatment of these patients. A clinical case of ergotism is presented in a 39-year-old woman, diagnosed with HIV 8 years ago, in stage B1 and under treatment with ritonavir 100 mg/day and atazanavir 300mg/day at the National Hospital of Clinics, Córdoba, Argentina.

Clinical Case

A 39-year-old woman, with no history of cardiovascular disease, diagnosed with HIV 8 years ago, in stage B1 under antiretroviral treatment with ritonavir 100 mg/day, atazanavir 300mg/day. He consulted at the Peripheral Health Center for headache and the therapy received consisted of ergotamine. The patient ingested 1 500 mg ergotamine tablet per day (Migral®). Forty-eight hours after starting therapy, he presented pain in both lower limbs with an insidious onset; accompanied by bilateral distal cyanosis, associated with decreased bilateral peripheral pulses, for which reason he required hospitalization and care in the Coronary Unit. On admission he is hemodynamically stable, cold, cyanotic lower limbs and without the presence of a popliteal, posterior tibial and foot pulse in the right lower limb, and absence of a posterior tibial and foot pulse in the left lower limb (Figure 1). Arterial Doppler ultrasound demonstrated patency of the entire arterial axis of both lower limbs with low resistance flow curves, likely related to drug-induced vasodilatation. A laboratory and chest X-ray were performed without pathological findings. Negative thrombophilia studies, in addition to cryoglobulins, cryogglutinins. Antiretroviral and ergotamine are suspended, a comprehensive parenteral hydration plan and calcium blockers (nimodipine 60 mg orally every 8 hours) associated with antithrombotic prophylaxis with enoxaparin 40 mg/day subcutaneously and antiplatelet therapy with acetylsalicylic acid (ASA) 200 mg are started. /day orally. With no significant response, angiography was performed which showed bilateral and symmetrical vasospasms causing insufficiency of the arteries in the lower extremities (Figure 2). An injection of 100 mg of prostacyclin was performed, without improvement. Intra-arterial infusion of 100 micrograms (µg) of nitro-glycerine (NTG) was decided with immediate improvement of the vasospasm (Figure 3). The patient evolves with marked improvement in the lower limbs, recovering peripheral pulses and cyanosis immediately, presence of bedsores (Figure 4). Nosocomial discharge on the fifth day, weekly controls by outpatient clinic, lower limbs with good evolution, without signs of subsequent ischemic events (Figure 5).

Figure 1: Bilateral distal cyanosis.

Figure 2: Subtraction angiography showing evidence of distal vasospasm with a significant reduction in irrigation.

Figure 3: Subtraction angiography after intra-arterial NTG injection, showing dilation and a considerable increase in irrigation.

Figure 4: Immediate post endovascular treatment with improvement of peripheral pulses and presence of scars.