Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Phlebologisch-Lymphologische Fallvorstellungen Felizitas Pannier Department of Dermatology University of Cologne Private Practice Phlebology & Dermatology Germany Case 1 •56-years old female patient •Referred to our phlebology department for treatment of chronic venous insufficiency •Cramps, feeling of heaviness and swelling of the ankle region every evening •No past history of varicose veins, phlebitis or deep venous thrombosis •Walking distance was not restricted •Often walked in the forests •On the lateral aspect of the right lower limb, in the ankle region an area of blue discoloration, atrophy of the skin and subcutaneous tissue Case 1 Doppler- and duplex-ultrasound investigation: normal superficial and deep venous system, normal ABI Serological investigation showed positive IgG and IgM-antibodies against Borrelia burgdorferi Diagnosis: Acrodermatitis chronica atrophicans PickHerxheimer Therapy: 14 days intravenously applied Ceftriaxon Significant improvement of the skin changes. 6 months later only positive IgGantibodies against Borrelia burgdorferi were found. Acrodermatitis chronica atrophicans PickHerxheimer A differential diagnosis for Chronic venous insufficiency Blue discoloration and skin atrophy in the ankle region, as well as edema are not only found in chronic venous insufficiency or other vascular diseases. In particular if venous investigations are normal, chronic infection by Burrelia burgdorferi has to be included in the differential diagnosis Case 2 64 year old woman 7 years ago after stripping of GSV she had developed a linear atrophy and fibrosis on both legs associated to the stripping channel 2-3 weeks after the operation Skin changes started at the incision areas, then spreading along the stripping chanel Later she developed lesions in the area of the non stripped, but insufficient short saphenous veins on both legs Case 2 Duplex: recurrent varicose veins of the GSV at both legs Laboratory routine findings: normal, a burrelia burgdorferi serology and antinuclear antibodies were negative Case 1 Histology: thick collagen fibre bundles and a perivascular, mostly lymphohistiocytic infiltration Diagnosis: Morphea (circumscript scleroderma Case 2 Morphea with Koebner-phenomenon after inflammation, trauma and operation is well discribed in literature. However we could only find one paper concerning morphea after stripping of the saphenous veins The authors describe three cases. Non of them showed development of morphea in the area of non operated insufficient veins. The question occurs if aside of the operation trauma, the varicose vein itself functions as an isomorphic trigger factor for morphea. This phenomenon is also known from Vitiligo Case 3 65 year old patient Atrial fibrillation Holidays in India 4 months ago After injury at the beach of left 1st toe 2 x 3 cm ulceration No healing, slight improvement with local antibiotics and antimycotics Ulceration of unknown origin Case 3 Venous or arterial ulcer? Embolism in atrial fibrillation? Local infection? Case 3 Histology: histiocytic cutanous inflammation Laboratory tests: normal Bacterial culture: Stapylococcus aureus pos. Mykologic culture: negative Parasitology: positive Leishmania titer 1:256 Skin biopsy: pos. Leishmania culture Leishmania species: Leishmania donovani Leishmaniosis Different types Cutaneous Leishmaniosis (Orientbeule): Leishmania tropica Mukokutaneous Leishmaniosis / Leishmaniosis of the New World Leishmania brasiliensis Visceral Leishmaniosis (Kalar Azar) Leishmania donovani Diagnosis Leishmaniosis: cutaneous infection with the species for visceral Leishmaniosis Tratment: Local? Systemic? Paramomycinsulfat Antimon intraläsional Ambisome (1. choice) Pentamidin Case 3 Before treatment Case 3 Local treatment: Paramomycinsulfat 15% in Uera pura 10% in Vaselinum album worsening of the ulceration Case 3 Ulcer after the 1st cycle of Ambisome Follow up: complete healing, no recurrence Case 4 71 year old man with polycythaemia vera - since 8 years 1500mg Hydroxycarbamid/d - since 6 months ulcerations left ankle - Duplex: PTS both legs, ABI normal Indications for Hydroxycarbamid Myeloproliferative Diseases - CML - Polycythaemia Vera - Thrombozytämia - Chronisc idiopathic Myelofibrosis Dermatologic side effects of Hydroxycarbamid Pigmentation Erythema Shingles Skin- and Nail atrophy Alopezia Dermatomyositis-like skin changes rarely: Skinulceration Ulcera at diagnosis 3 months after reduction of Hydroxycarbamid from1500mg/d to 500mg/d Similar case 80 year old woman with Polycythaemia vera - since 1 1/2 years 1000mg Hydroxycarbamid / d - since 9 months ulcerations on both legs - Duplex: venous and arterial normal - high blood pressure 12 weeks after stop of Hydroxycarbamid treatment Ulcera at diagnosis Case 5 41-year old female patient Since 2 years red, cold and painful right foot Resting pain Doppler- and Duplex: arterial occlusive disease in the right iliac and femoral artery Migraine since she was 18 years old. Since 8 years ergotamine up to every second day Case 5 Angiography: filiform stenosis of the right external iliac artery and of the femoral artery on the left side In general the arteriogram showed diffuse arterial spasm supporting the clinical diagnosis of egotism. Case 5 Echocardiographic examination revealed aortic, tricuspid and mitral valve insufficiency I°-II° No childhood history suggesting scarlet or rheumatic fever In the first-line treatment the patient abstained from ergotamine and nicotine abuse Intravenous infusion of prostaglandine was administered Rapid and complete improvement of arteriospasm in-between 8 days was noted, confirmed by further duplex examination Case 5 Ergotamine is known since the 6. century B.C. In the middle ages many hundred thousand people might have died of egotism epidemy. It was caused by food contamination with Claviceps purpurea. This is an ergotaminealkaloid producing mushroom. Because of the burning pain the disease was called St. Anthony’s fire Case 5 In this special case peripheral vasospasm was combined with cardiac valve insufficiency of three valves. This combination is very rarely reported in literature. The question stays if aside of vasospastic complications cardiac valve insufficiency can also be caused by ergotamine abuse. 1. Austin S, El-Hayek A, M Comoanos, D Tamulonis: Mitral Valve Disease associated with Long-Term Ergotamine Use: Southern Medical Journal 1993; 86 (10): 1179-81 5. Piquemal R, J Emmerich, J Guilmot, J. Fiessinger: Successful Treatment for Ergotism with Iloprost. Angiology 1998; 49 (6): 493-7 13. Wilke A, H Hesse, G Hufnagel, B Maisch: Mitral, aortic and tricuspid valvular disease associated with ergotamin therapy for migraine. Eur Heart J. 1997; 18 (4): 701 Case 6 50 year old man Right leg swelling since adolescence Episodes of cellulitis Diagnosis of lymphedema in a lymphologic hospital Treatment: Compression stockings Lymphatic drainage No improvement Case 6 Soft tumor No fibrosis Stemmer´s sign negative No pitting edema Case 6 Multiple Café au lait maculae Diagnosis: Morbus Recklinghausen (Neurofibromatosis Type 1) Autosomal dominant Family history negative No neurological tumors Case 7 11 year old girl After eating sweet and sour things within a few seconds intense präauricular reddening and warming Resolving within minutes after stopping eating No sweating in this region Normal chemosensoric function of fascialis nerve Case 7 3 years before first symptoms bothsided dislocated mandibular fracture after bycicle accident Asymmetric face X-ray: deformation of the left mandible (ramus ascendens) Case 7 Frey-Syndrome (auriculotemporal syndrome) is characterized by local sweating and reddening of the cheek after eating. Most frequent reasons are parotis operations or trauma. Pathophysiology of Frey-Syndroms consists of aberrant regeneration of parasympatisc nerve fibers. The auriculotemporal nerve, a branch of the trigeminus nerve innervates as well the glandula parotis with parasympathic fibers as subcutaneous blood vessels and sweat glands with sympathic fibers. After trauma of the nerve the regeneration can lead to parasympathic innervation of the blood vessels which was meant for the parotis gland. In this case Frey syndrome occured with reddening alone and without sweating, a variation of the syndrome. Case 8 Sclerotherpy - complications and risks Allergic reaction Skin necrosis Phlebitis Pigmentation Matting Nerve damage Visual disturbances Migraine like neurological disturbances Thromboembolic complications ESAF Study side effects pain hematoma phlebitis induration pigmentation itching Metallic taste Rabe et al. 2007, n = 108 liquid n = 53 6 7 6 3 4 2 3 (%) 11 13 11 6 8 4 6 foam n = 55 7 3 7 4 5 1 - (%) 13 5 13 7 9 2 - French Study (n= 12.173 sessions) -thromboembolic complicationsComplication Liquid Foam both DVT (V. fem. sup. 6 ml foam in GSV) 0 1 0 Muscle vein thrombosis 0 2 0 Perforator thrombosis 0 3 0 Thrombophlebitis 0 3 0 Guex et al. Dermatol Surg 2005; 31: 123-128 Late-onset phlebitis B. D.: female, 53 years old 07.03.2008: foam sclerotherapy tributary left medial lower leg 1% polidocanol, 1:5, 2ml no adverse reaction after 1 week at control 4 weeks later: phlebitis GSV, 10 cm, Duplex: vein not compressible, no DVT, no history of phlebitis or DVT Resolved with compression stocking after 10 days Late-onset phlebitis phlebitis tributary after sclerotherapy Late-onset phlebitis G. M.: female, 57 years old 09.04.2008: foam sclerotherapy of tributary varicose veins left thigh 1% and 0.5% polidocanol, 1:5, 4 ml, compression stocking 16.04.2008: all treated veins occluded, no side effects 28.04.2008: acute phlebitis of GSV at distal lower leg, duplex: GSV distally occluded, no DVT. No history of phlebitis or DVT. Late-onset phlebitis Phlebitis in a superficial vein First symptoms 2 – 6 weeks after foam sclerotherapy Short segments No clinical signs of phlebitis in between Late-onset phlebitis Patients after successful foam sclerotherapy No initial thromboembolic reaction Phlebitis in surrounding veins after 2 – 6 weeks Theory 1: Insufficient sclerosing effect Progression of thrombus after an interval Theory 2: Active foam has been kept enclosed in the treated and occluded vein. After some weeks thrombolysis of thrombus material may occur and minimal doses of still active polidocanol are set free. These low amounts are not able to sclerose the vein but cause local irritation of veins in the surroundings of the initially treated vessel. K.Parsi et al EJVES 2009; 38: 220-228: in vitro low concentrations of polidocanol have procoagulant activities Thank you very much for listening!