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Ergotism

Ergotism is a rare condition caused by ingestion of alkaloids produced by Claviceps purpurea fungi, most commonly through the use of drugs for migraine headaches (methylergometrine, ergotamine or ergotoxine) and concomitant administration of cytochrome P450 3A4 inhibitors, including antiretrovirals and macrolide antibiotics. Marked vasoconstriction and arterial insufficiency are the principal causes of symptoms.


Presentation

Symptoms stem from profound vasoconstrictive effects through blockade of alpha-adrenergic receptors, smooth muscle stimulation, and central sympatholytic activity, causing arterial insufficiency and development of both vascular and central nervous system complaints [1] [2]. Vasospasm can affect virtually any vessel in the body, but most commonly involves the femoral artery, which is why lower extremities are the principal site of symptom occurrence [3]. Initial reports showed that manifestations of ergotism may be seen as early as one hour after introduction of the harmful substance into the body [4], while other studies show that several days usually pass before the onset of symptoms [1]. Limb ischemia, burning pain, impaired sensation followed by numbness, appearance of cold and pale skin of the affected extremities, eventually leading to claudication and gangrene is the typical clinical course if the condition is not recognized on time, and loss of the affected extremity has been reported [1] [3] [4] [5] [6]. In addition, central nervous systems symptoms are encountered as well, having in mind the fact that ergot alkaloids are derivatives of lysergic acid (LSD), one of the most potent psychoactive substances [4]. Headaches, vertigo, hallucinations, mania, psychosis, convulsions (ranging from simple seizures to painful muscular contractions and tetanus-like cramps) and coma are constitutive features of ergotism [1] [4]. Gastrointestinal irritation can also occur. It presents as nausea, vomiting, diarrhea and cramping abdominal pain [2].

Limb Pain
  • Humans suffer from two varieties of ergotism and here are the associated symptoms, according to this 2007 Medicina article: Gangrenous ergotism (AKA ignis sacer or holy fire): nausea, limb pain.[tor.com]
Pallor
  • Loss of sensation, pallor and decrease in skin temperature of feet were observed. The patient denied taking any drug. An arterial Doppler test revealed the absence of flow in both tibioperoneal arteries.[pmj.bmj.com]
Vomiting
  • Definition (noun) poisoning by ingestion of ergot-infected grain products; characterized by thirst and diarrhea and nausea and cramping and vomiting and abnormal cardiac rhythms; in severe cases it can cause seizures and gangrene of the limbs[mnemonicdictionary.com]
  • […] the rye Convulsive and gangrenous Capiliaries contract, blood can't reach the body part Dry gangrene of the extremeties Lysurgic Acid Diethylamide Ignis Sacer, the Holy Fire Middle Age name for gangrenous ergotism Hallucination, epileptic convulsions, vomiting[quizlet.com]
  • 1 2 अर्गटिज़म Inflected forms ergotisms (noun plural) Definitions and Meaning of ergotism in English noun poisoning by ingestion of ergot-infected grain products; characterized by thirst and diarrhea and nausea and cramping and vomiting and abnormal cardiac[shabdkosh.com]
  • […] noun Poisoning produced by eating food affected by ergot, typically resulting in headache, vomiting, diarrhea, and gangrene of the fingers and toes. ‘But at the time, no scientist had connected those black seed grains with ergotism.’[en.oxforddictionaries.com]
Nausea
  • Definition (noun) poisoning by ingestion of ergot-infected grain products; characterized by thirst and diarrhea and nausea and cramping and vomiting and abnormal cardiac rhythms; in severe cases it can cause seizures and gangrene of the limbs[mnemonicdictionary.com]
  • 1 2 अर्गटिज़म Inflected forms ergotisms (noun plural) Definitions and Meaning of ergotism in English noun poisoning by ingestion of ergot-infected grain products; characterized by thirst and diarrhea and nausea and cramping and vomiting and abnormal cardiac[shabdkosh.com]
  • It presents as nausea, vomiting, diarrhea and cramping abdominal pain. The diagnosis of ergotism may be difficult to make, as approximately 0.001-0.002% of patients receiving ergot derivatives actually develop ergotism.[symptoma.com]
  • Other symptoms include strong uterine contractions, nausea, seizures, and unconsciousness. 13. Wait…Benefits???...[slideshare.net]
  • Humans suffer from two varieties of ergotism and here are the associated symptoms, according to this 2007 Medicina article: Gangrenous ergotism (AKA ignis sacer or holy fire): nausea, limb pain.[tor.com]
Hypertension
  • ., hypertension, lingual ischemia, and peripheral cyanosis) several hours after administration of her usual 2-mg dose of ergotamine tartrate.[ncbi.nlm.nih.gov]
  • Bromocriptine associated with postpartum hypertension, seizures, and pituitary hemorrhage. Gen Hosp Psychiatry. 1991;13:278-80. Katz M, Kroll D, Pak I, Osimoni A, Hirsch M.[revista.fecolsog.org]
  • ., et al : Different hemodynamic responses between acute and chronic infusion of Iloprost (prostacyclin-stable analogue) in severe pulmonary hypertension Am Rev Respir Dis 144: 1404 - 1405 , 1991 .[doi.org]
  • It was possible to identify a history of hypertension and/or preeclampsia only in nine cases, and a history of migraine in four. The vast majority of patients were otherwise healthy.[scielo.org.co]
Headache
  • Abstract Severe peripheral vasoconstriction of the legs due to hypersensitivity to small doses of ergotamine tartrate developed in a patient with migraine headaches.[ncbi.nlm.nih.gov]
  • Keywords Clinical Picture Daily Intake Migraine Patient Headache Patient Chronic Daily Headache These keywords were added by machine and not by the authors.[link.springer.com]
  • Abstract Severe extremity ischemia developed in four patients who had ingested methysergide maleate or ergot for the relief of headache. Symptoms involved the upper extremity in two patients and the lower extremity in two.[ncbi.nlm.nih.gov]
  • Abstract Ergotism is a rare condition of acute vasospasm found classically in young and middle-aged women taking ergot alkaloid agents to treat migraine headache.[ncbi.nlm.nih.gov]
Seizure
  • Definition (noun) poisoning by ingestion of ergot-infected grain products; characterized by thirst and diarrhea and nausea and cramping and vomiting and abnormal cardiac rhythms; in severe cases it can cause seizures and gangrene of the limbs[mnemonicdictionary.com]
  • […] plural) Definitions and Meaning of ergotism in English noun poisoning by ingestion of ergot-infected grain products; characterized by thirst and diarrhea and nausea and cramping and vomiting and abnormal cardiac rhythms; in severe cases it can cause seizures[shabdkosh.com]
  • Headaches, vertigo, hallucinations, mania, psychosis, convulsions (ranging from simple seizures to painful muscular contractions and tetanus-like cramps) and coma are constitutive features of ergotism. Gastrointestinal irritation can also occur.[symptoma.com]
  • Convulsive ergotism : painful seizures, spasms, convulsions. Hallucinations, mania or psychosis may occur.[tor.com]
Paresthesia
  • Anthony’s Fire. 1 The symptoms of ergotism consist of headaches, nausea, vomiting and diarrhea, paresthesias and itching, painful seizures and spasms, hallucinations, mania or psychosis.[hekint.org]
  • In both convulsive and gangrenous ergotism, the initial symptoms consist of gastrointestinal disturbances, vague flu-like symptoms, and distal extremity paresthesias.[visualdx.com]
  • On 5 December 1997, he complained of pain, paresthesias and cyanosis in both feet. He was admitted to Cochin Hospital on 8 December with severe pain in both legs. Loss of tibial, peroneal, but also radial and ulnar pulses was noted.[pmj.bmj.com]
  • Convulsive symptoms Edit Convulsive symptoms include painful seizures and spasms , diarrhea , paresthesias , itching, headaches, nausea and vomiting. Usually the gastrointestinal effects precede central nervous system effects.[psychology.wikia.com]
Stroke
  • Stroke. 1983 Sep-Oct;14(5):811-4. Abstract A 55-year-old woman with an aortic arch syndrome of acute onset and dysphasia, resulting from the excessive administration of ergotamine tartrate suppositories, is described.[ncbi.nlm.nih.gov]
  • Stroke. 1976 Jan-Feb;7(1):88-92. Abstract A patient with diffuse and focal cerebral dysfunction was found to have absent peripheral pulses. Cerbral angiography revealed evidence of an arteritis with bilateral high grade carotid stenosis.[ncbi.nlm.nih.gov]
  • Stroke. 1992 [visitado 2013 Feb 21];23:1364-6. Disponible en: Janssens E, Hommel M, Mounier-Vehier F, Leclerc X, Guerin du Masgenet B, Leys D. Postpartum cerebral angiopathy possibly due to bromocriptine therapy.[revista.fecolsog.org]
Confusion
  • However, a severe outbreak of something akin to ergot poisoning occurred in the French village of Pont-Saint-Esprit in 1951, resulting in five deaths. [6] The outbreak, and the diagnostic confusion surrounding it, are vividly described in John Grant Fuller[en.wikipedia.org]

Workup

The diagnosis of ergotism may be difficult to make, as approximately 0.001-0.002% of patients receiving ergot derivatives actually develop ergotism [3]. The workup, however, should be thorough and consist of several steps. Firstly, a thorough patient history to confirm the use of ergot-containing drugs and other agents that interfere with the cytochrome P450 3A4 system should be obtained, as ergot derivatives are metabolized through this cytochrome pathway in the liver [1]. Antiretrovirals, antidepressants, macrolide antibiotics (erythromycin, azithromycin), azole antifungals, but also grapefruit juice use the same pathway for metabolic degradation and virtually all patients who suffer from ergotism used some of the above-mentioned drugs [1]. Angiography is the cornerstone of evaluation of the vascular system in the setting of ergotism, and a generalized intense arterial spasm, the formation of collateral vessels (more commonly seen in prolonged toxicity) and thrombosis may be encountered [2]. Isolated spasms, multifocal stenoses, often described as "threadlike narrowing" of the vessel, is mentioned in various reports [2] [7], and a combination of medication history, clinical findings and results from angiography should be sufficient to make the diagnosis.

Treatment

  • The diagnosis may be made with the evidence of vascular ischemia in the presence of a history of migraines and its treatment with this drug.[ncbi.nlm.nih.gov]
  • . : Use of the prostacyclin analogue iloprost in the treatment of patients with critical limb ischemia Therapie 46: 319 - 322 , 1991 .[doi.org]
  • The patient is presented with a review of the pharmacology, toxicity, and treatment of ergotamine-induced ergotism.[ncbi.nlm.nih.gov]
  • The contribution of angiography in the diagnosis and treatment of ergotism is stressed.[ncbi.nlm.nih.gov]
  • The treatment of ergotism with sodium nitroprusside is reviewed and the apparent interaction of ergotamine and triacetyloleandomycin is discussed.[ncbi.nlm.nih.gov]

Etiology

  • When there was no laboratory confirmation of the arteritis, an iatrogenic etiology (ergotism) was suspected. This was later confirmed by the patient.[ncbi.nlm.nih.gov]
  • The local doctor, unsure of the etiology of their sickness, diagnosed the girls as having “bewitchment,” 1 a clinical judgment that led to the persecution and subsequent prosecution of the accused individuals.[jamanetwork.com]
  • […] simplex CMV infection Syphilis Pyoderma gangrenosum Sarcoidosis Amebiasis Deep mycosis Ulcerative neoplasm Ankle-brachial index (ABI) is a useful test for establishing whether the patient has ischemic disease, but it does not help pinpoint the underlying etiology[visualdx.com]
  • Ergotism: a possible etiology for puerperal psychosis. Obstet Gynecol. 1989 [visitado 2013 Feb 21];73(3 Pt 2):475-7. Disponible en:[revista.fecolsog.org]
  • The popularity of three-shi etiology derived in no small part from the fact that it united many streams of East Asian reflection on disease.[universitypublishingonline.org]

Epidemiology

  • The similarities between the clinical manifestations of ergotism and puerperal psychosis, and some of the epidemiologic features of the latter condition, appear to implicate ergot alkaloids as potential causative agents.[ncbi.nlm.nih.gov]
  • ISSN: 0950-2688 EISSN: 1469-4409 URL: /core/journals/epidemiology-and-infection Unfortunately you do not have access to this content, please use the Get access link below for information on how to access this content.[journals.cambridge.org]
  • IV.2 - Maternal Mortality: Definition and Secular Trends in England and Wales, 1850-1970 pp 214-224 By Irvine Loudon Export citation View abstract Summary This chapter talks about the historical epidemiology of maternal mortality, the distribution and[universitypublishingonline.org]
Sex distribution
Age distribution

Prevention

  • Abstract Ergot's derivatives are widely used to treat and prevent migraine and, associated with heparin, for the prevention of deep vein thrombosis.[ncbi.nlm.nih.gov]
  • The therapy for the vasospasm is directed chiefly at the discontinuation of the ergot preparation, with further treatment aimed at the relief of symptoms or prevention of complications.[ncbi.nlm.nih.gov]
  • Control/Prevention None. Avoid the use of wheat, oats, and rye grass in the feed formulation. Withdrawal of suspected feed.[pig333.com]
  • Ergotamine: It is used medicinally for treatment of acute migraine attacks (sometimes in combination with caffeine), and to induce childbirth and prevent post-partum haemorrhage.[slideshare.net]
  • Prevention [ edit ] Removal of ergot bodies is done by placing the yield in a brine solution; the ergot bodies float while the healthy grains sink. [2] Infested fields need to be deep plowed; ergot cannot germinate if buried more than one inch in soil[en.wikipedia.org]

References

Article

  1. Fröhlich G, Kaplan V, Amann-Vesti B. Holy fire in an HIV-positive man: a case of 21st-century ergotism. CMAJ. 2010;182(4):378-380.
  2. Garcia GD, Goff JM Jr, Hadro NC, O'donnell SD, Greatorex PS. Chronic ergot toxicity: A rare cause of lower extremity ischemia. J Vasc Surg. 2000;31(6):1245-1247.
  3. Brancaccio G, Celoria GM, Falco E. Ergotism. J Vasc Surg. 2008;48(3):754.
  4. Alm T, Elvevåg B. Ergotism in Norway. Part 1: The symptoms and their interpretation from the late Iron Age to the seventeenth century. Hist Psychiatry. 2013;24(1):15-33.
  5. Ayarragaray JE. Ergotism: a change of persepective. Ann Vasc Surg. 2014;28(1):265-268
  6. Molkara AM, Abou-Zamzam AM Jr, Teruya TH, Bianchi C, Killeen JD. Chronic ergot toxicity presenting with bilateral external iliac artery dissection and lower extremity rest pain. Ann Vasc Surg. 2006;20(6):803-808.
  7. Jeong SY, Lim ES, Shin BS, et al. Ergotism With Ischemia In All Four Extremities: A Case Report. J Clin Neurol. 2006;2(4):279-282.

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Last updated: 2017-08-09 18:11