Male, 47 years old, history of headaches since adolescence under treatment with high doses of ergotamine, HIV diagnosed in 2005.
He began to receive 10 days prior to the consultation ARVT based on: zidovudine, lamivudine, indinavir/ritonavir, presenting at four days intense pain, paresthesias and paresis of the hands.
Physical examination revealed coldness, semiflexion of the fingers of both hands and absence of bilateral ulnar and radial pulse.
The diagnostic approaches in these 3 HIV-positive patients with acute cutaneous manifestations in acral areas that due to their characteristics corresponded to vascular phenomena were: firstly a cutaneous vasculitis, knowing the frequent association between this disease and HIV.
However, the absence of pulses and the involvement of only distal limbs together with the clear symptoms of ischemia suggested that the picture could correspond to acute arterial embolism, but the bilaterality of the process distanced this plant.
Finally, given that we were dealing with multimedicated patients, it was proposed whether the clinical picture could not be of toxic-drug cause.
With these hypotheses tests were requested to assess the symptoms and signs of peripheral ischemia.
In all three cases Doppler ultrasound showed elements of diffuse arterial spasm and uniform reduction in caliber of the affected arteries without evidence of thrombosis, suggesting a functional alteration.
In case 2, an arteriography of the upper limbs showed thinning of the cubital and radial arteries with total obliteration of their distal sector and absence of flow in the interosseous arteries.
Basic laboratory tests showed no abnormalities in any of the patients and anti smooth muscle antibodies, cryoglobulins, cryoglutinins and serological for hepatitis B and C virus were negative in all 3 cases.
1.
Facing an acute vasomotor syndrome with acrocia, associated with ergonomic signs and arteriography secondary to peripheral vascular insufficiency in HIV patients treated with ritonavir who self-medicated with ergotamine, ergotamine exclusion was diagnosed.
The central element of the therapeutic conduct was the suspension of the drugs involved: ergotamine and ritonavir.
All 3 patients received treatment based on arterial vasodilators of the type nifedipine at doses of 30 mg every 8 hours orally and pentoxyphylline at doses of 400 mg every 8 hours orally for a period of 10 days.
Antiplatelet therapy with acetylsalicylic acid 250 mg/day was administered orally and prophylactic anticoagulation with enoxaparin 40 mg/day subcutaneously for the same period of time.
Cases 1 and 2 presented complete resolution of the clinical picture on the tenth day, with normalization of the flow of the affected arteries by control Doppler, while in the third patient had an excellent evolution, being discharged asymptomatic on the sixth day.
