Successful treatment of digital ulcers in a scleroderma patient with continuous bilateral thoracic sympathetic block.

Abstract

BACKGROUND: Raynaud's phenomenon (RP) associated with connective tissue disease (secondary RP) may be difficult to manage with conservative therapy. A combination of sympathetically mediated vasospasm and vaso-occlusion has been implicated as the etiology of digital ischemic phenomenon. Thoracic sympathetic outflow blocking has been performed with various techniques. However, there have been some limitations in all treatment options.

OBJECTIVE: We report on a patient with medically refractory digital ulceration and gangrene caused by scleroderma who was successfully treated with a continuous infusion of mepivacaine into the thoracic sympathetic ganglions as a means to improve finger circulation.

CASE REPORT: We are reporting on a 32-year-old female patient suffering from a medically intractable gangrenous ulcer in the right third finger and the left second and third fingers, accompanied by aching pain (VAS, visual analogue scale, 5 - 6/10) and numbness in both forearms. She underwent continuous infusion of mepivacaine through the thoracic sympathetic catheter placed in T2 vertebral segment for 13 days on the right and for 11 days on the left and cervical epidural infusion of mepivcaine with fentanyl for 10 days after the medical treatment failed. Her finger temperature increased 2 degrees C - 5 degrees C during the thoracic sympathetic block with continuous infusion of mepivacine. Her finger wounds healed completely with 13 days of the continuous thoracic sympathetic block without any complications.

CONCLUSIONS: Continuous infusion of mepivacaine into the thoracic sympathetic ganglionic space led to the healing of the medically refractory gangrenous ulcer of the fingers in the patient with scleroderma.