Skin necrosis and calcifications after extravasation of vancomycin: a localised form of calciphylaxis?

Vancomycin is a tricyclic glycopeptide antibiotic produced from Streptococcus orientalis. There is much variation in the literature with regard to the recommended dose, dilution rate and type of infusion. Given the vesicant properties of vancomycin at supratherapeutic doses (>10mg/ml), tissue damage including blistering and necrosis have been reported. We report a rare case of bilateral cutaneous necrosis induced by accidental extravasation of vancomycin when being intravenously administered. The skin surrounding the injection site was marked by the appearance of subcutaneous calcifications. The development of iatrogenic skin calcinosis has not yet been described for the extravasation of vancomycin. The mechanism underlying the calcinosis observed in our case remains unclear, but we hypothesised a form of localised calciphylaxis induced by a local triggering factor. The ulcers progressed to re-epithelialisation following necrosis debridement and local conservative treatments. Given the increased prevalence of meticillin-resistant Staphylococcus aureus, which has prompted clinicians to gradually increase vancomycin dosage, clinicians should be aware of the high risk of skin toxicity in cases of vancomycin high-dose extravasation.

A case of cutaneous necrosis due to intra-articular hyaluronic acid and treated with hyaluronidase

A 66-year-old woman presented to the hospital with cutaneous necrosis of her right ankle and foot. Her symptoms began immediately after an intra-articular injection of hyaluronic acid for ankle osteoarthritis, which was performed 6 days before. Histopathology showed an intra-vascular hyaluronic acid embolus. The initial treatment approach was conservative, but the patient’s clinical state degraded. She was thus treated with sub-cutaneous hyaluronidase, the enzyme that degrades hyaluronic acid, which yielded a moderate improvement even though it was administered 22 days after the initial hyaluronic acid injection. Although hyaluronic acid embolism and subsequent cutaneous necrosis are well-known complications of dermal fillers, there are few reported cases of embolism following intra-articular injection. To our knowledge, this is the first time hyaluronidase has been used in this setting.

Painful Retiform Purpura with Cutaneous Necrosis

Levamisole-induced vasculitis is characterized by a painful, purpuric rash in a retiform or stellate pattern with or without central necrosis that commonly involves the trunk, extremities, digits, distal nose, cheeks, and ear helices. This clinical syndrome is associated with the use of levamisole-adultered cocaine. Histologic findings for levamisole-induced vasculitis are not disease specific but may include leukocytoclastic vasculitis, microvascular thrombosis, and panniculitis. Laboratory findings of levamisole-induced toxicity include agranulocytosis, neutropenia, hepatotoxicity, glomerulonephritis, pulmonary hemorrhage, and positive p-ANCA, c-ANCA tests, ANA, or lupus anticoagulant. The differential diagnosis for levamisole-induced vasculitis includes leukocytoclastic vasculitis, drug reaction, cryoglobulinemia, idiopathic thrombocytopenic purpura, granulomatosis with polyangiitis, Churg-Strauss syndrome, and polyarteritis nodosa. Levamisole-induced vasculitis typically resolves spontaneously with cessation of cocaine use however; recurrence is common following re-exposure.