Letter to the Editor
Fat necrosis and subcutaneous abscesses due to apomorphine
Necrosis grasa y abscesos subcutáneos por apomorfina
Elena García-Zamora
, Marta Elosua-González, Uxúa Floristán-Muruzábal
Corresponding author
Hospital Universitario Fundación Alcorcón, Dermatología, Madrid, Spain
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Symptomless indurated, abscessed and fistulizated cutaneous plaques on abdomen and thigh.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Parkinson's disease (PD) is one of the most prevalent movement disorders and the most common neurodegenerative cause of parkinsonism. It often affects male over 50 years. Nowadays, there are many treatment options available, such as levodopa, catechol-O-methyltransferase (COMT) inhibitors, dopamine agonists, anticholinergic drugs or monoamine oxidase type B (MAO-B) inhibitors. Most of these drugs can have adverse effects, including skin reactions<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 53-year old male with a 10-year history of PD presented with multiple symptomless indurated, abscessed and fistulizated cutaneous plaques involving abdomen, arms and thighs for about 3 months (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Three years before he had suffered from secondary syphilis, treated with 3 intramuscular doses of penicillin G benzathine. He was currently under therapy with venlafaxine, trazodone, levodopa/benserazide and for almost 2 years with subcutaneous apomorphine. As most PD patients under therapy with subcutaneous apomorphine, our patient used both intermittent subcutaneous injections (arms and thighs) and infusion via pump (abdomen).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Physical examination showed that injuries coincided with the location of the injections of the drug.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Sonography of the biggest plaque on abdomen demonstrated a small subcutaneous mesogastrio collection, which was drained. A sample was sent to microbiological culture, which confirmed a secondary methicillin-susceptible Staphylococcus aureus infection. A skin biopsy was performed, showing extensive dermoepidermal fibrosis with chronic lymphoplasmacytic inflammatory infiltrate. In the hypodermis, fat necrosis was present, with fatty cysts and hemosiderin deposit. The microbiological culture of the biopsy and anti-treponemal immunohistochemistry were negative.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Intravenous antibiotic therapy with amoxicillin/clavulanate was instaured with partial improvement. However, although other therapeutic options were offer, the patient refused the withdrawal of apomorphine.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Apomorphine is a specific dopaminergic agonist usually given subcutaneously, used in the treatment of severe fluctuations of PD, particularly in patients on levodopa.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Even in newer drug formulations, skin reactions can be problematic in long term treatment. Reported cutaneous side effects of the drug include pruritic subcutaneous nodules corresponding to panniculitis in up to 20%, allergic contact dermatitis, pigmented nodules resulting from oxidation of apomorphine and severe forms like necrosis in 3–10% of long term treated patients.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a> There are few cases of biopsy-proven apomorphine induced localized skin necrosis. Although the mechanism underlying most adverse skin reactions in response to the injection of subcutaneous apomorphine is unknown, cutaneous necrosis could arise though various mechanisms: localized vasoconstriction, direct toxicity of the injected drug, local manifestations of pre-existent coagulation disorders, immunological mechanisms or poor administration technique involving intravascular injection.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "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" => 677 "Ancho" => 1300 "Tamanyo" => 123441 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation. Symptomless indurated, abscessed and fistulizated cutaneous plaques on abdomen and thigh.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A 10 years retrospective audit of long-term apomorphine use in Parkinson's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.L. Tyne" 1 => "J. Parsons" 2 => "A. Sinnott" 3 => "S.H. Fox" 4 => "N.A. Fletcher" 5 => "M.J. 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