Multiple organ dysfunction induced by alprostadilum in a patient diagnosed with scleroderma (systemic sclerosis)

Abstract

Introduction: Painful, slow-healing ulcers of the fingers are most common in patients with progressive systemic sclerosis. Prostaglandine E1(PGE1) is a vasodilatator that has been found to reduce the pain of the severe periphereal arterisclerotic vascular disease and to promote healing of the accompanying ulcers. Clinical case: We present the case of a 46-years old, female, allergic to Hymenoptera venom, and witch in 2010 received swine flu vaccine. In october 2010, she reach on the departament of Rheumatology, Targu Mures accusing pain and swelling in the extremities, skin changes at the same level accompanied by vasomotor disturbances at cold. Having in mind this clinical appearance of skin, typical for scleroderma, Associated with the mesenchymal nonspecific inflammatory syndrome proven by laboratory test, with increased antibody titer (antinuclear antibodies-ANA: 45.2 UI/ml and topoisomerase-I antibodies-anti Scl 70: 39.5 UI/ml) and after radiographic appearance of early resorption of the distal phalanx, IV finger, right hand is given a diagnosis of progressive systemic scleroderma and we have initiated a background treatment with methotrexate. But after two months the disease progresses rapidly with necrotizing vasculitis and pulmonary injury. So we initiated a treatment with cyclophosphamide 600 mg intravenously with favorable evolution until October 2011 when it stopped due to a suspected hemorrhagic cystitis, and when peripheral ischemia occur we decide to introduce back azathioprine in the treatment plan but with modest results resuming the treatment with Cyclophosphamide in May 2012, which was Associated with Alprostadilum and in February 2013reenter Methotrexate. In january 2014,after the treatment with Alprostadilum, the patient suddenly accuse chills, low grade fever, muscular pain, without auscultatory lung changes, arrhythmic heart sounds, with ischemic changes on electrocardiogram, rising the suspicion of an acute coronary syndrome, but which was rejected after cardiological examination. Subsequently, after two days, the patient presents coffee grounds vomiting for which was made an upper gastrointestinal endoscopy in emergency, which shows no active bleeding source. Concidering progressive hemodynamic alterations, the patient is transferred in Gastroenterology Clinic where is established the diagnosis of acute gastric ulcer with upper gastrointestinal bleeding. After 2 weeks, the patient presents in the emergency room in bad general condition with necrotic changes in the fingers and she was hospitalized to the intensive care unit with inflammatory syndrome, marked anemia, hepatic and renal failure, pleural effusion fluid with cytopathology diagnosis of atypical cells and suspected neoplastic process having a rapidly evolution to death.In conclusion even if we considered all aspects and risk factors related to the patient’s disease, when we prescribe Alprostadilum we should expect to face a tragic outcome.