Purple Glove Syndrome

 

Mrs. Shaiji M J

Assistant Professor, Droan College of Nursing, Vill and Post, Khanpur Purab Dineshpur Road,

 Rudrapur-263153, Uttarakhand

 

ABSTRACT:

Purple glove syndrome (PGS) is a rare complication of intravenous phenytoin use which typically presents with pain, edema, and discoloration at the injection site that spreads to the distal limb. Several risk factors have been associated with the development of PGS; however, the etiology remains unknown. Treatment is supportive, and most cases resolve within days to weeks.

 

 

 

INTRODUCTION:

Glove syndrome is a rare, but very serious adverse effect that may lead to limb amputations. This may occur due to the administration of phenytoin with or without extravasation. Purple glove syndrome is an uncommon but dreaded complication of intravenous phenytoin administration characterized by pain, edema and purple-blue discoloration of the limb distal to the site of injection.^[1]

 

Definition:

Purple glove syndrome: 

(PGS) is a poorly understood skin disease in which the extremities become swollen, discolored and painful. PGS is potentially serious, and may require amputation. 

 

Stages:

PGS development encompasses 3 stages.^[2]

First stage:

During the first stage, which occurs within 2 to 12 hours after infusion of IV phenytoin, a dark purple-bluish discoloration of the skin appears around the site of IV phenytoin infusion.

 

Second stage:

In the second stage, which occurs in the next 12 to 16 hours, edema develops and there is progression of the dark purple-bluish discoloration around the skin surrounding the infusion site.

 

Third stage:

During the final stages of PGS, healing occurs with resolution of edema and receding of skin tissue discoloration. PGS has been described as being painful through all of its stages.

 

Pathology:

The true pathology of purple glove syndrome is not fully elucidated, however it is believed to be due to the crystallization of phenytoin within the blood and extravasates into the surrounding interstitium. Another mechanism may be due to the disruption of endothelial transcellular junctions followed by leaking of phenytoin into the surround soft tissues.^[3]

 

Signs and symptoms:

·       The area appeared dark blue and purple in color

 

·         Swelling

·         Erythematous                                                                        

·         Warm to touch

·         Blistering,

·         Pulses and sensation may be diminished

·         Skin necrosis may develop

Adverse Drug Reaction Probability Scale (Naranjo):

The Adverse Drug Reaction (ADR) Probability Scale was developed in 1991 by Naranjo and coworkers from the University of Toronto and is often referred to as the Naranjo Scale.  This scale was developed to help standardize assessment of causality for all adverse drug reactions and was not designed specifically for drug induced liver injury.  The scale was also designed for use in controlled trials and registration studies of new medications, rather than in routine clinical practice.  Nevertheless, it is simple to apply and widely used. 

 

The ADR probability scale consist of 10 questions that are answered as either Yes, No, or “Do not know”. Different point values (-1, 0, +1 or +2) are assigned to each answer. A simplified version of the 10 questions is provided below:^[7]

 

 

Assessing phenytoin-induced PGS using Naranjo Adverse Drug Reaction Probability Scale

Questions	Yes	No	Do not know	Phenytoin score
Are there previous conclusive reports on this reaction?	+1	0	0	+1
Did the adverse event appear after the suspected drug was administered?	+2	-1	0	+2
Did the adverse reaction improve when the drug was discontinued or specific antagonist was administered?	+1	0	0	+1
Did the adverse event reappear when the drug was re-administered?	+2	-1	0	0
Are there alternative causes (other than the drug) that could on their own have caused the reaction?	-1	+2	0	+2
Did the reaction reappear when a placebo was given?	-1	+1	0	0
Was the drug detected in blood (or other fluids) in concentrations known to be toxic?	+1	0	0	0
Was the reaction more severe when the dose was increased or less severe when the dose was decreased?	+1	0	0	0
Did the patient have a similar reaction to the same or similar drugs in any previous exposure?	+1	0	0	0
Was the adverse event confirmed by any objective evidence?	+1	0	0	+1
Total				7

 

Differential diagnosis of purple glove syndrome:

·       Intravenous infiltration

·       Cellulitis

·       Acrocyanosis

·       Raynaud’s phenomenon

·       Livedo reticularis

·       Polyarteritis nodosa

·       Buerger’s disease

 

Treatment: 

·       Discontinue the use of phenytoin.

·       The application of heat can help to relieve pain.

·       The arm keeps elevated and dry heat can apply.

·       Topical nitroglycerin patch can use for intense pain was not relieved with parental non steroidal anti-inflammatory drugs, brachial plexus can block.

·       Some authors have suggested that the use of fosphenytoin, the pro-drug of phenytoin, may be preferred if PGS is a concern, but data regarding this indication are limited. Fosphenytoin, which is usually less toxic, compared with phenytoin, is soluble at a lower pH, can be less painful upon extravasation, and can be given through either intravenous or intramuscular injection. However, the cost is substantial, and recent studies of cost-effectiveness do not support regular use. ^[4]

·       On very rare occasions, PGS may progress to necrosis, ischemia, vascular compression, or compartment syndrome, which may require surgical interventions such as fasciotomy, skin grafting, or rarely amputation.^[5]

 

REFERENCE:

1.      Chokshi R, Openshaw J, Mehta NN, Mohler E (February 2007). "Purple glove syndrome following intravenous phenytoin administration". Vasc Med. 12 (1): 29–31. doi:10.1177/1358863X07076551. PMID 17451091.

2.      O'Brien TJ, Cascino GD, So EL, Hanna DR (October 1998). "Incidence and clinical consequence of the purple glove syndrome in patients receiving intravenous phenytoin". Neurology. 51 (4): 1034–9. doi:10.1212/wnl.51.4.1034. PMID 9781525.

3.      Jain, Rajendra Singh; Nagpal, Kadam; Kumar, Sunil; Prakash, Swayam; Handa, Rahul (2015). "Purple glove syndrome occurring after oral administration of phenytoin in therapeutic doses: Mechanism still a dilemma". The American Journal of Emergency Medicine. 33 (1): 123.e5–123.e6. doi:10.1016/j.ajem.2014.05.039. PMID 25064142.

4.       Hanna DR. Purple glove syndrome: A complication of intravenous phenytoin. J Neurosci Nurs. 1992;24(6): 340–345. [PubMed] [Google Scholar]

5.       Chokshi R, Openshaw J, Mehta NN, Mohler E., 3rd Purple glove syndrome following intravenous phenytoin administration. Vasc Med. 2007;12(1):29–31. [PubMed] [Google Scholar]

6.       Burneo JG, Anandan JV, Barkley GL. A prospective study of the incidence of the purple glove syndrome. Epilepsia. 2001;42(9):1156–1159. [PubMed] [Google Scholar]

7.      Busto U, Naranjo CA, Sellers EM. Comparison of two recently published algorithms for assessing the probability of adverse drug reactions. Br J Clin Pharmacol 1982; 13: 223 PubMed Citation  (Comparison of two scales for adverse drug reactions found both to have inter reviewer reliability of >95%, but the Naranjo scale was easier and faster to fill out)

 

 

Received on 06.08.2019         Modified on 30.08.2019

Accepted on 17.09.2019      ©A&V Publications All right reserved