Phenytoin in wound healing.

OBJECTIVE: To describe a patient with a massive Grade IV pressure ulcer that responded rapidly to treatment with topical phenytoin and to review the literature supporting the use of this therapy. CASE SUMMARY: A 55-year-old morbidly obese white man (266 kg), with respiratory failure secondary to obesity-hypoventilation syndrome and heart failure, developed pressure ulcers on his lower back and sacrum with the first 2 weeks of hospitalization. Traditional methods of treatment were unsuccessful, and by day 79, the wound involved the entire lumbosacral area and buttocks, and had extensive undermining and sinus tract formation. Within 2 days of applying topical phenytoin, fresh granulation was apparent. After 54 days of treatment, nearly all the sinus tracts were healed. Four months after treatment with topical phenytoin had facilitated the healing of the wounds, even though the patient's multiple underlying medical problems had not resolved. DISCUSSION: Phenytoin has been used in the healing of pressure sores, venous stasis and diabetic ulcers, traumatic wounds, and burns. Many of the existing clinical studies have methodologic flaws, such as inappropriate statistical analysis, inadequate control groups, and the absence of randomization and double-blinding. Nevertheless, all the studies have reported enhancement of wound healing, with insignificant adverse effects. Phenytoin may promote wound healing by a number of mechanisms, including stimulation of fibroblast proliferation, facilitation of collagen deposition, glucocorticoid antagonism, and antibacterial activity. CONCLUSIONS: Phenytoin promoted the healing of a massive necrotizing soft tissue wound that was unresponsive to conventional treatment. Clinical success in this difficult case and the other reports in the literature suggest that phenytoin is effective in would healing and deserves further investigation.

Possible erythromelalgia-like syndrome associated with nifedipine in a patient with Raynaud's phenomenon.

OBJECTIVE: To describe a patient who was diagnosed with Raynaud's phenomenon, was prescribed immediate-release nifedipine, and developed a possible erythromelalgia-like syndrome. CASE SUMMARY: A 24-year-old white woman with a history of esophageal spasms and Raynaud's phenomenon was prescribed nifedipine 10 mg po qid. Approximately 1 hour after the patient had taken the fourth dose of nifedipine, she experienced acute erythema and a burning sensation in her feet and lower limbs, light-headedness, and palpitations. Because of a reportedly abnormally low blood pressure, the patient took diphenhydramine 50 mg po and proceeded to the clinic. On arrival, abnormal vital signs were BP 140/48 mm Hg and HR 130 beats/min. Without any other medical intervention, approximately 30 minutes later her blood pressure and heart rate had returned to baseline at 122/60 mm Hg and 96 beats/min, respectively. The nifedipine was permanently discontinued and the patient's symptoms completely resolved over 24 hours. DISCUSSION: The characteristic symptoms of erythromelalgia include burning pain, increased skin temperature, and erythema of the extremities, usually to the feet, lower legs, and, less often, the hands. Erythromelalgia-like syndromes secondary to the administration of many medications have been reported. Several nifedipine-related reports describe an erythromelalgia-like syndrome similar to our reported case. CONCLUSIONS: Because the patient was not taking any other medications and the symptoms started with the administration of nifedipine and were relieved after its discontinuation, nifedipine was thought to be the cause of the erythromelalgia-like syndrome.

Intranasal butorphanol-induced apraxia reversed by naloxone.

Intranasal butorphanol is an opioid agonist-antagonist that is effective for the treatment of acute pain. Common adverse effects associated with the agent are somnolence, dizziness, nausea, and vomiting; they are readily reversed with naloxone. A patient developed signs and symptoms consistent with apraxia after a single dose of intranasal butorphanol. She was mentally alert, but she was unable to move or speak despite normal muscle tone and reflex movements. When she attempted to speak she had no voluntary control. At the emergency room she was administered naloxone 2 mg intramuscularly, which resulted in complete reversal of the symptoms in a short time. No other published cases describe these findings with butorphanol. Health care professionals should be aware that patients who are prescribed intranasal butorphanol, even in typical doses, may be at risk for such a reaction. This is important because, unlike the injectable formulation, the intranasal product is primarily used in the outpatient setting.