Caso clínico
Sildenafil in severe peripheral ischemia induced by terlipressin. A case report
Sildenafil en isquemia periférica severa inducida por tarlipresina. Reporte de un caso
David D. Bañuelos Ramíreza,
, Silvia Sánchez Alonsoa, María Magdalena Ramírez Palmab
Autor para correspondencia
davra43@yahoo.com
Corresponding author at: Retorno del Bronce núm 5, Fracc San Bernardo-Glez Ortega, Puebla, Pue. México, CP 72040.
Corresponding author at: Retorno del Bronce núm 5, Fracc San Bernardo-Glez Ortega, Puebla, Pue. México, CP 72040.
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"nombre" => "José Antonio" "apellidos" => "Nieto Rodríguez" ] 3 => array:2 [ "nombre" => "Eva" "apellidos" => "García Alberdi" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X10001099?idApp=UINPBA00004M" "url" => "/1699258X/0000000700000001/v1_201305061846/S1699258X10001099/v1_201305061846/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Sildenafil in severe peripheral ischemia induced by terlipressin. A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59" "paginaFinal" => "60" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "David D. Bañuelos Ramírez, Silvia Sánchez Alonso, María Magdalena Ramírez Palma" "autores" => array:3 [ 0 => array:4 [ "nombre" => "David D." "apellidos" => "Bañuelos Ramírez" "email" => array:1 [ 0 => "davra43@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Silvia" "apellidos" => "Sánchez Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "María Magdalena" "apellidos" => "Ramírez Palma" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Specialty Consult Rheumatology, Unidad Médica Alta Especialidad, Hospital de Especialidades, Centro Médico Nacional, Instituto Mexicano del Seguro Social, Puebla, Pue, México" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Médico Familiar, Adscrita a Unidad Médico Familiar 01, Instituto Mexicano del Seguro Social, Puebla, Pue, México" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Retorno del Bronce núm 5, Fracc San Bernardo-Glez Ortega, Puebla, Pue. México, CP 72040." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sildenafil en isquemia periférica severa inducida por tarlipresina. Reporte de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 2465 "Tamanyo" => 413364 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sequential pictures of the patient's evolution. Despite treatment with dermic nitroglycerin and other vasodilatator drugs, necrotic areas, ischemic and other lesions are showed (picture A and B). At day 25 sildenafil starts to show a good response which is observed in picture C.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 51 year-old woman came to the emergency room with a history of alcoholic cirrhosis, portal hypertension, and esophageal varices (previously treated with sclerotherapy) and chronic renal failure, with her last creatinine clearance measured at 40<span class="elsevierStyleHsp" style=""></span>ml/h. She was classified as Child-Pugh C. She had presented upper digestive tract bleeding for 12<span class="elsevierStyleHsp" style=""></span>h. After 24<span class="elsevierStyleHsp" style=""></span> with persistent hemorrhage, intravenous terlipressin was added to the management (4<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h); on the third day after treatment, she developed cyanosis of the toes, and the terlipressin was discontinued immediately. These changes progressed to ischemia and extended throughout the feet, accompanied by poor peripheral pulses and tissue damage as shown in <a class="elsevierStyleCrossRef" href="#fig0005">figure 1</a>-A. Because of her blood loss, acute renal failure developed, with an elevation of serum creatinine from 1.9<span class="elsevierStyleHsp" style=""></span>mg/dl on the first day to 8<span class="elsevierStyleHsp" style=""></span>mg/dl, and she developed grade IV hepatic encephalopathy; serum bilirubin was normal and an arterial and venous Doppler ultrasound was performed showing no signs of obstruction and normal flows. Because of the lack of response to management we started treatment with oral sildenafil 50<span class="elsevierStyleHsp" style=""></span>mg twice per day. At the third day she showed great improvement and sildenafil 75<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h was continued for two more weeks. She preserved her toes. At this point, she had grade I encephalopathy, and also had improvement of renal function with a reduction in serum creatinine to 3.2<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Finally, at day 30, the patient was completely recovered, with normal serum creatinine, a normal neurological state and healthy skin (<a class="elsevierStyleCrossRef" href="#fig0005">fig. 1</a>-C).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Sen et al described a possible toxic effect of terlipressin related to its vasoconstrictor action.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Terlipressin has been associated with peripheral ischaemia<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and vasculitis-like lesions, like the ones observed in this case. Sildenafil is a selective inhibitor of GMP-phosphodiesterase with an effect on microvascular and macrovascular circulation, approved for use in erectile dysfunction, pulmonary arterial hypertension, and recently described by Fries et al for use in Raynaud's phenomenon in cases not showing a response to common vasodilator therapy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Kumana et al has informed of sildenafil use in the presence of ischemia and tissue necrosis, with improvement of three severe cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The effect obtained from the use of sildenafil, due to vasodilatation, could be considered as an effective therapy in cases of ischemia secondary to terlipressin, like the case above, when some other vasodilators agents cannot be indicated due to deleterious effects like hypotension. Another beneficial effect of sildenafil could be an increase of renal arterial flow with improvement of renal function in acute renal failure; the latter should be investigated to a larger extent. Sildenafil opens the possibility of use in ischemia of another etiology, and should be the object of more study as an alternative drug or even as the first option, alone or associated to other vasodilators, in severe cases of ischemia.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–8</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "xres126142" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec113439" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres126143" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec113438" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2009-12-18" "fechaAceptado" => "2010-05-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec113439" "palabras" => array:3 [ 0 => "Terlipressine" 1 => "Ischemia reversal" 2 => "Sildenafil" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec113438" "palabras" => array:3 [ 0 => "Tarlipresina" 1 => "Isquemia reversible" 2 => "Sildenafil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A female patient in the sixth decade of life developed renal failure secondary to gastrointestinal bleeding, which was non-responsive to conventional therapy. She was treated with terlipressin iv; showing improvement but developing, over the next few days, ischemia and necrosis of the toes in the lower extremities, simulating necrotizing vasculitis, without response to regular management. An alternative therapy, oral sildenafil 50<span class="elsevierStyleHsp" style=""></span>mg BID, was used, with a rapid reversal of the clinical picture. The vasodilator action of sildenafil is useful in cases of ischemia induced by some drugs. The objective this report is to warm about the utility of sildenafil in some potentially severe cases, like the one above.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Una paciente de la sexta década de la vida desarrolló fallo renal secundario a hemorragia digestiva incoercible, con datos de choque hipovolémico, por lo que fue tratada con tarlipresina iv, con lo que hubo mejoría, pero presentó isquemia y necrosis de los dedos en extremidades inferiores, simulando vasculitis necrotizante sin respuesta al manejo terapéutico habitual, por lo que se empleó como alternativa sildenafil oral 50 mg 2 veces al día, con reversión rápida de su cuadro clínico. La acción vasodilatadora del sildenafil demostró ser una opción útil en el presente caso y el objetivo de esta comunicación es alertar de la respuesta satisfactoria al sildenafil en casos de isquemia inducida por medicamentos, semejantes a lo que se presenta en la práctica médica.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 2465 "Tamanyo" => 413364 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sequential pictures of the patient's evolution. Despite treatment with dermic nitroglycerin and other vasodilatator drugs, necrotic areas, ischemic and other lesions are showed (picture A and B). At day 25 sildenafil starts to show a good response which is observed in picture C.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Terlipressin-induced vasoconstriction reversed with N- acetylcystein: a case for combined use in hepatorenal syndrome?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Sen" 1 => "R. Moorkerjee" 2 => "R. Jalan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/gast.2002.37303" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology." 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 17 | 16 | 33 |
| 2024 Octubre | 100 | 30 | 130 |
| 2024 Septiembre | 111 | 18 | 129 |
| 2024 Agosto | 97 | 35 | 132 |
| 2024 Julio | 91 | 36 | 127 |
| 2024 Junio | 114 | 25 | 139 |
| 2024 Mayo | 113 | 35 | 148 |
| 2024 Abril | 80 | 32 | 112 |
| 2024 Marzo | 60 | 37 | 97 |
| 2024 Febrero | 61 | 21 | 82 |
| 2024 Enero | 72 | 17 | 89 |
| 2023 Diciembre | 54 | 26 | 80 |
| 2023 Noviembre | 56 | 31 | 87 |
| 2023 Octubre | 67 | 31 | 98 |
| 2023 Septiembre | 89 | 45 | 134 |
| 2023 Agosto | 63 | 15 | 78 |
| 2023 Julio | 61 | 29 | 90 |
| 2023 Junio | 67 | 20 | 87 |
| 2023 Mayo | 71 | 31 | 102 |
| 2023 Abril | 50 | 12 | 62 |
| 2023 Marzo | 51 | 26 | 77 |
| 2023 Febrero | 61 | 42 | 103 |
| 2023 Enero | 45 | 21 | 66 |
| 2022 Diciembre | 85 | 50 | 135 |
| 2022 Noviembre | 64 | 23 | 87 |
| 2022 Octubre | 53 | 44 | 97 |
| 2022 Septiembre | 1653 | 40 | 1693 |
| 2022 Agosto | 84 | 46 | 130 |
| 2022 Julio | 52 | 39 | 91 |
| 2022 Junio | 40 | 49 | 89 |
| 2022 Mayo | 44 | 37 | 81 |
| 2022 Abril | 59 | 54 | 113 |
| 2022 Marzo | 41 | 48 | 89 |
| 2022 Febrero | 43 | 39 | 82 |
| 2022 Enero | 53 | 37 | 90 |
| 2021 Diciembre | 46 | 38 | 84 |
| 2021 Noviembre | 43 | 42 | 85 |
| 2021 Octubre | 95 | 48 | 143 |
| 2021 Septiembre | 59 | 39 | 98 |
| 2021 Agosto | 37 | 45 | 82 |
| 2021 Julio | 38 | 37 | 75 |
| 2021 Junio | 38 | 36 | 74 |
| 2021 Mayo | 51 | 48 | 99 |
| 2021 Abril | 81 | 96 | 177 |
| 2021 Marzo | 37 | 33 | 70 |
| 2021 Febrero | 39 | 28 | 67 |
| 2021 Enero | 40 | 31 | 71 |
| 2020 Diciembre | 33 | 34 | 67 |
| 2020 Noviembre | 46 | 24 | 70 |
| 2020 Octubre | 26 | 14 | 40 |
| 2020 Septiembre | 37 | 29 | 66 |
| 2020 Agosto | 29 | 23 | 52 |
| 2020 Julio | 42 | 35 | 77 |
| 2020 Junio | 42 | 39 | 81 |
| 2020 Mayo | 57 | 40 | 97 |
| 2020 Abril | 36 | 33 | 69 |
| 2020 Marzo | 58 | 42 | 100 |
| 2020 Febrero | 52 | 34 | 86 |
| 2020 Enero | 60 | 49 | 109 |
| 2019 Diciembre | 74 | 49 | 123 |
| 2019 Noviembre | 43 | 19 | 62 |
| 2019 Octubre | 38 | 44 | 82 |
| 2019 Septiembre | 38 | 49 | 87 |
| 2019 Agosto | 40 | 31 | 71 |
| 2019 Julio | 71 | 39 | 110 |
| 2019 Junio | 66 | 30 | 96 |
| 2019 Mayo | 79 | 100 | 179 |
| 2019 Abril | 78 | 32 | 110 |
| 2019 Marzo | 86 | 27 | 113 |
| 2019 Febrero | 67 | 18 | 85 |
| 2019 Enero | 65 | 31 | 96 |
| 2018 Diciembre | 83 | 59 | 142 |
| 2018 Noviembre | 81 | 13 | 94 |
| 2018 Octubre | 90 | 23 | 113 |
| 2018 Septiembre | 63 | 19 | 82 |
| 2018 Agosto | 47 | 18 | 65 |
| 2018 Julio | 13 | 4 | 17 |
| 2018 Mayo | 3 | 2 | 5 |
| 2018 Abril | 41 | 10 | 51 |
| 2018 Marzo | 60 | 4 | 64 |
| 2018 Febrero | 35 | 6 | 41 |
| 2018 Enero | 68 | 9 | 77 |
| 2017 Diciembre | 103 | 5 | 108 |
| 2017 Noviembre | 94 | 8 | 102 |
| 2017 Octubre | 110 | 14 | 124 |
| 2017 Septiembre | 77 | 8 | 85 |
| 2017 Agosto | 120 | 6 | 126 |
| 2017 Julio | 74 | 5 | 79 |
| 2017 Junio | 130 | 8 | 138 |
| 2017 Mayo | 86 | 6 | 92 |
| 2017 Abril | 139 | 4 | 143 |
| 2017 Marzo | 163 | 29 | 192 |
| 2017 Febrero | 160 | 7 | 167 |
| 2017 Enero | 148 | 2 | 150 |
| 2016 Diciembre | 186 | 18 | 204 |
| 2016 Noviembre | 258 | 12 | 270 |
| 2016 Octubre | 306 | 20 | 326 |
| 2016 Septiembre | 227 | 16 | 243 |
| 2016 Agosto | 30 | 13 | 43 |
| 2016 Julio | 16 | 8 | 24 |
| 2016 Marzo | 1 | 0 | 1 |
| 2016 Febrero | 4 | 0 | 4 |
| 2016 Enero | 1 | 0 | 1 |
| 2015 Diciembre | 4 | 0 | 4 |
| 2015 Noviembre | 1 | 0 | 1 |
| 2015 Octubre | 4 | 13 | 17 |
| 2015 Septiembre | 1 | 0 | 1 |
| 2015 Agosto | 3 | 0 | 3 |
| 2015 Julio | 103 | 5 | 108 |
| 2015 Junio | 178 | 6 | 184 |
| 2015 Mayo | 155 | 15 | 170 |
| 2015 Abril | 113 | 10 | 123 |
| 2015 Marzo | 108 | 10 | 118 |
| 2015 Febrero | 133 | 1 | 134 |
| 2015 Enero | 73 | 0 | 73 |
| 2014 Diciembre | 76 | 0 | 76 |
| 2014 Noviembre | 65 | 0 | 65 |
| 2014 Octubre | 64 | 0 | 64 |
| 2014 Septiembre | 43 | 0 | 43 |
| 2014 Agosto | 46 | 0 | 46 |
| 2014 Julio | 42 | 0 | 42 |
| 2014 Junio | 78 | 0 | 78 |
| 2014 Mayo | 57 | 0 | 57 |
| 2014 Abril | 59 | 0 | 59 |
| 2014 Marzo | 62 | 10 | 72 |
| 2014 Febrero | 48 | 10 | 58 |
| 2014 Enero | 42 | 7 | 49 |
| 2013 Diciembre | 44 | 6 | 50 |
| 2013 Noviembre | 24 | 4 | 28 |
| 2013 Octubre | 53 | 7 | 60 |
| 2013 Septiembre | 55 | 11 | 66 |
| 2013 Agosto | 32 | 14 | 46 |
| 2013 Julio | 36 | 4 | 40 |
| 2013 Junio | 35 | 5 | 40 |
| 2013 Mayo | 28 | 5 | 33 |
| 2013 Abril | 31 | 8 | 39 |
| 2013 Marzo | 47 | 5 | 52 |
| 2013 Febrero | 27 | 3 | 30 |
| 2013 Enero | 29 | 10 | 39 |
| 2012 Diciembre | 33 | 3 | 36 |
| 2012 Noviembre | 18 | 4 | 22 |
| 2012 Octubre | 12 | 6 | 18 |
| 2012 Septiembre | 14 | 6 | 20 |
| 2011 Mayo | 2 | 0 | 2 |
| 2011 Abril | 5 | 0 | 5 |
| 2011 Marzo | 8 | 0 | 8 |
| 2011 Febrero | 22 | 0 | 22 |
| 2011 Enero | 21 | 0 | 21 |
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