Initial patients IA, female, 57 years old, with morbid history of hypertension and hypothyroidism.
Three months prior to the current condition, the patient was hospitalized for polyarthralgia, diarrhea syndrome, weight loss and alopecia.
The etiologic study diagnosed HIV (+), with CD4 count of 44 cells/mL and started treatment with lamivudine, zidovudine, atazanavir, ritonavir and cotrimoxazole.
Hypoacia was present in the emergency service of Hospital San Juan de Dios de los Andes, due to clinical picture of asthenia, nausea and paresthesia of the four extremities, progressing to intense pain, peripheral coldness,
Physical examination revealed a blood pressure of 134/107, normal heart rate, saturing pulse of 98%, temperature of 37 °C. The patient presented with a painful face, without lymphadenopathy, cardiopulmonary and abdominal examination findings.
Examination of the extremities revealed the presence of a left hand acrocia pulsatility with capillary refill, intense pain upon palpation, partially conserved strength, poiquilotermia, radial pulse, and non-ulcer medications.
Osteotendinous reflexes were preserved.
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In the lower extremities palpable acrocia was detected from the ankle, with slow capillary refill, paresis, poiquilotermia, pedal and tibial pulses not.
Violet color in the left foot with more pain
preserved osteotendinous grafts
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Tests were requested: blood count, renal function, plasma electrolytes and liver function, whose results were normal.
The patient was hospitalized with the diagnosis of acute ischemia of the four limbs, starting with non-steroidal heparin, analgesia and requested appler of the extremities, which reported: permeable echocardiography axillary and smoke permeable.
Cubital and radial arch with progressive flow reduction with antegrade monophasic and distal flow curves.
In the common, superficial and deep femoral arteries, the flow velocities and morphology of the preserved spectral waves.
No flow was observed in the anterior or posterior distal tibial arteries, no flow was observed in the dorsalis pedis arteries.
Location through collaterals in the anterior region of the right foot.
The patient had severe pain and was admitted to the intermediate treatment unit.
When asked, she did not report any antecedents that could guide the diagnosis; however, one relative reported that the patient had long-standing headaches and frequent use of Migranol®.
Considering this background, the diagnosis of ergotism due to the use of ergotamine associated with antiretroviral therapy (ART) was established.
ART was discontinued and vasodilatation was initiated with nitroglycerin continuous infusion, nor with a 20 mg c/12 h pump or pentoxyphylline 400 mg c/8 h pump.
Within the first 48 h she had a favorable clinical course, with less pain in the upper limbs, palpable pulses and recovered strength.
In lower limbs pain also decreased, with more strength and palpable pulses.
However, pulses of the left foot were still tapered.
At 72 h, the pulse was already on the four limbs, without pain, with conserved force.
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Subsequently, the patient responded favorably, restarted HAART at 5 days, and prophylactic therapy for migraine was prescribed.
Education on the risks of drug interactions was performed and medical discharge was indicated.
