Renal infarction due to ergotamine

H.K. Sran, A. Vathsala
2016 QJM: Quarterly journal of medicine  
Ergotamine can cause severe vasoconstriction leading to organ ischaemia, even with doses within the recommended therapeutic range. Exercise caution when prescribing ergotamine especially on a chronic basis. Case presentation A 54-year-old Caucasian male non-smoker presented to the Emergency Department with severe left loin pain of sudden onset for the last 3 h. He reported frequent migraines for the last 20 years, for which he had been taking occasional ergotamine 1 mg/caffeine tablets,
more » ... over-the-counter overseas. The migraines had worsened recently, attributed to stress at work and therefore he had been taking the ergotamine almost daily. On the day prior to admission, he had taken three tablets over 24 h, and reported increasingly severe episodes of loin pain occurring about 1 h after administration of the second and third doses. Examination revealed left renal angle tenderness and vital signs included temperature 36.7 C, blood pressure 129/75, pulse 62/min, pulse oximetry 99% on air. Bedside abdominal ultrasound was unremarkable. Dipstick urinalysis and microscopy, and serum Creatinine were normal. C-reactive protein was mildly elevated at 15 mg/L. Contrast enhanced computed tomography (CT) of the abdomen revealed left renal infarcts (Figure 1 ). Twentyfour hour electrocardiogram revealed normal sinus rhythm throughout. Echocardiogram was normal with no intracardiac thrombus. Thrombophilia screen was unremarkable. In view of the temporal relation of symptoms to ergotamine intake, without other underlying causes, we attributed renal infarction to the ergotamine. In view of his low-normal blood pressure of 100-110/60-70, he was not commenced on intravenous nitrates, in case this reduced renal perfusion pressure, further exacerbating the infarcts. He was treated with intravenous fluids and analgesia, and symptoms resolved. Renal function remained stable, likely due to unilateral involvement and the lack of significant renal parenchymal loss. MAG3 scan performed 4 days after the initial presentation showed a persistent left renal upper pole defect; however, the left lower pole infarct had resolved (Figure 2) . The Neurologist advised amitriptyline for his migraines. 3 months later, renal function remained stable and he had improved control of migraines, without ergotamine. He had no further episodes of loin pain. Discussion Renal infarction occurs rarely, commonly caused by thromboemboli from intracardiac sources, renal artery injury and Figure 1. Computed tomography showing left renal infarct.
doi:10.1093/qjmed/hcw163 pmid:27654501 fatcat:qskevrzxjbegvgqekdn6sfe3da